Prior to the start of each legislative session, the Legislative Budget Board (LBB) and the Governor’s Office of Budget, Policy and Planning jointly issue instructions to each Texas state agency regarding how to develop their Legislative Appropriations Request (LAR). An LAR is the agency’s budget request for money to operate their programs over the next two-year biennium — Fiscal Years (FY) 2018–2019. An LAR usually includes exceptional item requests for priorities that the agency considers of great importance in addition to the base budget. At the beginning of the legislative session, the House and Senate propose budgets for Texas state agencies that may include some exceptional item requests as part of the base budget. Those that do not make it into the base in the introduced budget may remain under consideration throughout the appropriations process.
The Texas Health and Human Services Commission (HHSC) released its FY 2018–2019 LAR to the public on Friday, September 16, 2016. The HHSC LAR is seven volumes, 2,458 pages, and includes 64 exceptional items. Because parts of the Department of Aging and Disability Services (DADS), the Department of Assistive and Rehabilitative Services (DARS), the Department of Family and Protective Services (DFPS), and the Department of State Health Services (DSHS) consolidated into HHSC on September 1, the HHSC LAR is massive in comparison to prior biennia.
Budget instructions required HHSC to reduce its base budget request by 4%. The following programs were recommended for elimination or reduction in order to meet the 4% budget reduction requirement:
- Program Elimination:
- DADS In-Home Family Support Program, $10 million
- Lifespan Respite program, $1 million
- Relocation specialist function, $5 million
- Program Reduction:
- Child Care Licensing (CCL) and Adult Protective Services (APS), $1.7 million
- Blindness Education, Screening, and Treatment (BEST) and Comprehensive Rehabilitation (CRS), $3 million
The LAR also includes 14 options for reducing the base budget by an additional 10%.
The Texas Council for Developmental Disabilities staff reviewed the HHSC LAR and summarized the exceptional items and budget reduction options that could impact people with intellectual and developmental disabilities (IDD). In the summary below, the General Revenue (GR), or state funds, are identified where possible. Due to complicated methods of finance, only the All Funds (AF) figure is provided for some items. In some cases, the GR and AF number is the same, which means only state funds are requested.
Below are the 64 exceptional items included in HHSC’s budget request:
- Exceptional Item 1 Medicaid Entitlement Cost Growth
$3.3 billion All Funds
The exceptional item would maintain Medicaid entitlement program cost growth for all acute and long-term services and supports entitlement services. LBB instructions required cost growth, including utilization and acuity changes, medical inflation, or evolving or new services to be requested as an exceptional item. The Federal Medical Assistance Percentage (FMAP) rates of 56.24% for FY 2018 and 56.25% for FY 2019 are assumed in this item, with an additional match of 6% for Community First Choice (CFC).
Exceptional Item 2 CHIP Cost Growth
$8.1 million Tobacco Funds, $106.4 million All Funds
Exceptional Item 3 Community Living Assistance and Support Services Cost Growth
$21.2 million General Revenue, $48.4 million All Funds
Increases in Community Living Assistance and Support Services (CLASS) waiver client acuity and service utilization costs are projected to increase by 3% per year.
- Exceptional Item 4 Maintain Waiver Caseloads
$29.9 million General Revenue, $70.2 million All Funds
The LBB’s budget instructions did not allow HHSC to prepare a draft budget request that continues to pay for waiver services that the 84th Texas Legislature said it funded. Although the 84th Texas Legislature appropriated funds to provide services to people waiting on interest lists, they did not authorize all of the people to receive services on the first day of the biennium. Instead they were authorized to prepare an interest list reduction schedule so that offers are evenly distributed across the 24 months in the biennium. Budget instructions required the agency to build the base budget by including levels at only an average of the two previous years. Because half of the people identified had yet to receive services at the time of the calculation, the funds used to pay for services started toward the biennium could not be included in the base. This routine practice requires people with disabilities to make multiple requests for the same services. If not funded, people expecting waiver offers in 2017 will not receive them or people who are receiving services at the end of the biennium, particularly in the Home and Community-based Services (HCS) waiver program, will lose their waiver services on August 31, 2017.
Exceptional Item 5 Maintain Community Mental Health Services Programs
$4.7 million General Revenue/All Funds
The following programs require funding to maintain FY 2017 levels:
- Relinquishment Prevention (DFPS — Residential Treatment Center Bed Expansion) — If not funded, 7% fewer children would be served in residential treatment centers (30 to 28).
Youth Substance Abuse Prevention — If not funded, about 51,414 fewer youth would receive expanded substance abuse prevention services, a 28% reduction.
Neonatal Abstinence Syndrome Program — If not funded, 160 fewer infants would receive opioid treatment services, a 25% reduction.
Recovery-Focused Clubhouses — If not funded, 138 fewer people would access services, a 36% reduction.
Supported Decision-Making Program in State Hospitals — If not funded, 14 fewer people would be diverted from unnecessary guardianship, a 14% reduction.
Exceptional Item 6 Maintain Early Childhood Intervention Caseloads
$44.76 million All Funds
Funding for this exceptional item is to maintain FY 2017 Early Childhood Intervention (ECI) caseloads. Federal Individuals with Disabilities Education Act (IDEA) Part C regulations require all children determined eligible for the program to be served. To reduce state funding for the program, the Texas Legislature narrowed ECI eligibility criteria in FY 2012. However, the ECI program has historically seen growth in the number of children served while federal IDEA Part C funding has remained relatively level. Consequently, many providers have to resort to fundraising in order to fully meet the needs of children with developmental delays in their ECI programs. If additional funding is not appropriated, decision makers may further narrow eligibility criteria.
Exceptional Item 7 Maintain Enhanced Service Coordination and Transition Support
$13 million General Revenue
Funding for enhanced community coordination and transitional support teams funded through Money Follows the Person (MFP) Demonstration funds will not be available after FY 2017. DADS must continue current enhanced community coordination to ensure that necessary medical and/or behavioral services for individuals with complex needs are accessed, coordinated, and delivered in a person-centered manner:
- This item maintains funding for an enhanced array of services and supports to help local IDD authorities (LIDDAs) and community providers successfully transition people into community settings, including: service coordination for residents of nursing facilities and state-supported living centers (SSLCs); pre- and post-move monitoring; and flexible spending support.
This item maintains Texas’ eight regional support teams to provide technical assistance and preventive measures statewide to expand the expertise of LIDDAs and community providers related to specific disorders and diseases. Furthermore, this item ensures that LIDDAs continue to provide enhanced services and supports and identify regional challenges or gaps in available medical, psychiatric, and behavioral resources.
Exceptional Item 8 Maintain Psychiatric Bed Capacity
$121 million General Revenue
The state psychiatric hospital system is expected to lose capacity due to a variety of factors. Maintaining this capacity is important to ensure access to care close to home and in closer proximity to local law enforcement.
- Exceptional Item 9 Maintain SSLC and State Hospital Staffing
$68.8 million General Revenue, $96 million All Funds
This exceptional item would fund salary increases at SSLCs to address staff turnover and compliance with intermediate care facility (ICF) regulations and the federal Department of Justice settlement agreement.
Exceptional Item 10 Adult Protective Services and Child Care Licensing
$5.1 million General Revenue, $6 million All Funds
In order to stay within appropriated levels, the agency has used funds intended to hire staff to fund operational costs instead. This practice has resulted in a backlog that negatively impacts other areas of health and human services including a backlog of long-term services and supports provider investigations. This item would fund:
- Operational support costs, like travel, cell phones, leases and information technology (IT), for Child Care Licensing (CCL) and Adult Protective Services (APS) Provider Investigations ($5 million General Revenue), and;
Purchase of license rights to a quality assurance software package that will enhance CCL’s quality assurance and program improvement efforts ($70,000 General Revenue).
Exceptional Item 11 Sunset/Transformation Costs, Senate Bill 208 2015
$18.3 million General Revenue/All Funds
This would fund anticipated — but unfunded — costs associated with the 2015 decision to transfer Vocational Rehabilitation (VR) to the Texas Workforce Commission (TWC), as VR administrative funds were used to partially support field support staff for Comprehensive Rehabilitation Services (CRS), Children’s Blindness Services, and Independent Living Services (ILS).
Exceptional Item 12 Restore 4% Reductions to Blindness Education, Screening, and Treatment and Comprehensive Rehabilitation Services Programs
$1.3 million General Revenue/All Funds
The BEST program provides treatment for eye conditions that pose an imminent risk of permanent or significant visual loss.
The Comprehensive Rehabilitation Services (CRS) Program provides time-limited mobility, self-care, and communication skills to help Texans with a traumatic brain injury or spinal cord injury to live independently. CRS maintains a waiting list and a 4% reduction would result in additional people on the waiting list.
Exceptional Item 13 Restore Reduction to Child Care Licensing and Adult Protective Services (DFPS)
$1.7 million General Revenue/All Funds
Exceptional Item 14 Promoting Independence
$50.1 million General Revenue, 114.5 million All Funds
This item provides the following new Promoting Independence services to persons who would otherwise be entitled to more expensive institutional services:
The number of people who will receive Promoting Independence services Promoting Independence Groups Number of People HCS for People Moving from SSLCs 400 HCS for People Moving from Large ICFs 100 HCS for Youth Aging out of Foster Care 236 HCS for Persons at Imminent Risk of Entering an ICF 400 HCS for People with IDD Moving from State Hospitals 120 HCS for Children Moving from a general residence operations (GRO) facility (DFPS) 40 HCS for People with IDD moving from nursing facilities 700 HCS for People with IDD at risk of entering a nursing facility 600 Medically Dependent Children’s Program (MDCP) services for children at risk of entering a nursing facility (NEW) 550
- Exceptional Item 15 Interest List Reduction
$346 million General Revenue, $803.4 million All Funds
This item says it funds 19,010 “slots,” but does not provide detail about how they would be allocated across waivers. Therefore, reviewers are unable to provide further analysis regarding how many people (by waiver) could receive waiver service offers.
- Exceptional Item 16 Community Mental Health Wait List Reduction
$8.2 million General Revenue/All Funds
Though unclear, the detail suggests that this item funds the impact of population growth on community mental health waiting lists.
Exceptional Item 17 Independent Living Services and Comprehensive Rehabilitation Services Waiting List Reduction
$10.4 million General Revenue/All Funds
The ILS program provides services to eligible Texans with significant disabilities, including veterans, with support to improve their ability to function independently in their home and the community. Most requests involve the purchase of assistive technologies and devices. Comprehensive Rehabilitation Services (CRS) reduces the need for ongoing state services. CRS maintains a waiting list.
Exceptional Item 18 Institution Repairs and Renovations
$189.6 million GO Bonds
This item would fund health and safety renovations in state hospitals and SSLCs. The repairs and renovations include electric panels, fire alarm systems, emergency generators, roofing, HVAC systems, water and waste water lines, etc.
Exceptional Item 19 Institution Repairs Laundry Facilities
$5.4 million General Revenue/All Funds
Requested exceptional item funding would be used to support 10-year replacement plan for laundry facilities. Includes vehicles and building expansion and demolition required as a result of laundry facility consolidation. NOTE: FY 2014–15 funding included a combination of bond funding totaling $70 million for said consolidation.
Exceptional Item 20 Institutions Vehicles
$15.8 million General Revenue/All Funds
Funds vehicle replacement schedule.
Exceptional Item 21 Institutions New Construction of State Hospitals and SSLCs
$1 million General Revenue/All Funds
Placeholder pending legislative direction to construct new institutions.
Exceptional Item 22 Psychiatric Bed Capacity
$100.7 million General Revenue/All Funds
This item would fund staff and operations to add 96 beds to Vernon State Hospital. This expansion would reduce the number of people waiting in jail for a maximum security bed. It would also fund the purchase of an additional 100 beds from public and private entities around the state to ensure availability of beds to meet the demand. The state hospital long-term plan identified a significant unmet need for an additional 600 beds over the next 10 years.
Exceptional Item 23 Family Planning Services
$20 million General Revenue, $20 million All Funds
Exceptional Item 24 Family Violence Program
$3 million General Revenue, $3 million All Funds
Exceptional Item 25 Court Appointed Special Advocates and Child Advocacy Centers
$8 million General Revenue, $8 million All Funds
This item would increase availability of Court Appointed Special Advocates (CASA) and Child Advocacy Centers (CAC) services.
Exceptional Item 26 Intensive Behavioral Intervention for People with Autism
$14.3 million General Revenue, $32.8 million All Funds
This item would fund a new program/service called Intensive Behavioral Intervention (IBI) to address maladaptive behaviors among people with Autism Spectrum Disorder (ASD). Program would assess people for IBI treatment options and deliver a treatment plan to addresses targeted issues and goals. A contracted entity would assist with development of medical policy, prior authorization criteria and conduct utilization review for the first two years of the benefit. This entity would also develop policy regarding caregiver involvement, and establish criteria for demonstrating adequate progress toward goals for continued service authorization. Does not include behavior analyst licensing.
Exceptional Item 27 Hepatitis C Treatment
$19.8 million General Revenue/All Funds
- Exceptional Item 28 Enhanced Mental Health Community Services
$44.5 million General Revenue/All Funds
This item would increase the intensity of adult and children’s mental health services in communities with minimal services; provide an additional 15 RTC beds to youth who are at risk of parental relinquishment; stabilize the current substance abuse provider base and increase access to services and supports; and create Outpatient Competency Restoration — in a high demand area of the state to decrease demand for state hospital beds.
Exceptional Item 29 Sale of State-Supported Living Centers Services to Persons in the Community
$19.3 million All Funds
This item funds staff to operate clinics at 12 state-operated SSLCs for people with IDD in community-based settings. SSLCs would leverage their existing space and staff. DADS estimates the annual cost to operate the clinics to be $1.07 million per clinic. Through Medicaid waiver services billing, DADS expects the operating costs to be partially offset during the FY18–19 biennium, and become cost neutral in the next biennium. Two SSLCs were scheduled to initiate a pilot program (September 2016) to offer dental waiver services, but the Center for Medicare and Medicaid Services (CMS) recommended that Texas NOT implement a pilot to provide community services in institutional settings. They remain in negotiations to determine whether the pilot may be limited to acute services only.
Exceptional Item 30 Aging and Disability Resource Centers Supports for Veterans
$1.3 million General Revenue/All Funds
This item would fund Aging and Disability Resource Centers (ADRC) to ensure staff have the expertise to link veterans to service options. The ADRC cost to serve a veteran is more than three times the average cost ($235 compared to $72). This item would also allow for education and cross-training activities for veteran services organizations and ADRC aging and disability network partners.
Exceptional Item 31 Program of All-Inclusive Care for the Elderly Shortfall
$5.1 million General Revenue, $11.6 million All Funds
This item would eliminate the Program of All-Inclusive Care for the Elderly shortfall for the next biennium. PACE has received a funding reduction to their reimbursement rates for several years due to a shortfall in appropriated amounts. If not funded, the program will receive an approximate 12% reduction in the next biennium.
Exceptional Item 32 ICF Quality Monitoring
$6.8 million General Revenue, $13.7 million All Funds
This item would fund 79 additional staff to restructure ICF policy and contract requirements, stakeholder communication, financial and performance management, utilization review, and manage MCO health plan and drug formularies among other items.
Exceptional Item 33 Maintain Regulatory Workload Assisted Living Facilities and Day Activity and Health Services
$3.9 million General Revenue, $5.8 million All Funds
This item would fund 36 additional staff to keep up with surveys, inspections, and complaint and incident investigations particularly for assisted living facilities (ALFs) and Day Activity and Health Services (DAHS, formerly adult day care). Workload has increased by 30% since FY 2006.
Exceptional Item 34 Federal Childcare Licensing Requirement Compliance
$12.1 million All Funds
Exceptional Item 35 Staff to Control APS and Day Care Licensing Caseloads
$17.4 million All Funds
Exceptional Item 36 Litigation and Legal Assistance
$3.2 million All Funds
This item would fund 12 legal staff to defend the state in relation to the foster care lawsuit and Steward v. Abbott, the class action lawsuit regarding inappropriate placement of people with IDD in nursing facilities.
Exceptional Item 37 Mortality Review of Individuals with Intellectual Developmental Disabilities
$1.7 million General Revenue, $3.5 million All Funds
Independent mortality reviews have long been required for deaths of individuals with IDD who, at the time of the person’s death, receive publicly-funded services; however, only SSLC resident death reviews were ever implemented. The mortality review data is intended to be used to identify trends, as well as system-wide improvements.
- Exceptional Item 38 Community Attendant Wages
$156 million General Revenue, $364 million All Funds
This item would increase the wage floor from $8 per hour to $8.50 per hour, a 6.25% increase.
Exceptional Item 39 Wage Enhancement for Intellectual Developmental Disabilities Programs
$8.5 million General Revenue, $21.5 million All Funds
This rate enhancement program incentivizes providers who agree to spend about 90% of their total attendant-related revenues on attendant compensation with additional wage supports. This would allow providers to participate in the program at higher levels.
Exceptional Item 40 Day Habilitation Compliance
$30.6 million General Revenue, $70 million All Funds
This item is included to bring Texas into compliance with the CMS Home and Community-Based Services (HCBS) Settings Rule. The agency’s primary proposed strategy is to assist waiver providers and their subcontracted day habilitation providers with rate increases. Though no specifics are provided, the item also anticipates additional services, adding services to the existing service array and providing for increased contract oversight of program providers.
The federal HCBS Settings Rule require states to ensure all locations in which HCBS services are provided meet criteria regarding community integration and self-determination, setting choice, the right to privacy, dignity and respect, and individual autonomy. Texas must be in compliance by March 17, 2019. The Children’s Policy Council and the IDD Statewide Redesign Advisory Committee have approved specific recommendations to improve day habilitation. Their reports are expected this fall.
Exceptional Item 41 Community Critical Incident Reporting
$1.3 million General Revenue, $2.5 million All Funds
This item would contract with a vendor to provide a web-based critical incident reporting system designed to meet the business, security, and reporting requirements of HHSC and contracted service providers.
Exceptional Item 42 Quality Reporting System Updates
$614,000 General Revenue, 1.2 million All Funds
This item funds a 2015 Sunset recommendation, in part, by replacing the 15-year-old Quality Reporting System (QRS). The QRS is used by individuals and families to make informed provider selections. Currently, most LIDDAs provide only a long list a providers contracted with the state to provide services. This replacement request would offer individuals the opportunity to make recommendations regarding criteria to include in the QRS, like percent of clients employed or percent of clients supported to live in more independent living settings.
Exceptional Item 43 Information technology for PreAdmission Screening and Resident Review Long Term Care Online Portal Improvement
$4.1 million General Revenue, $16.5 million All Funds
This item would fund Information technology improvements to the Long Term Care (LTC) Online Portal for claims and authorization transmission for specialized services not covered by managed care but required under the PreAdmission Screening and Resident Review (PASRR) program. It would replace a paper-based process. This item may also put the state in more of a defensible position by addressing some issues associated with a class action lawsuit by ensuring that people with IDD in nursing facilities receive specialized services like employment and habilitation.
Exceptional Item 44 Information Technology for ReHabWorks Replacement
$3.3 million General Revenue
As a result of the DARS Sunset and transfer of VR to TWC, ownership of ReHabWorks for Case Management transferred to TWC on September 1, 2016. ReHabWorks supports CRS, Blind Children’s Vocational Discovery and Development Program (BCVDDP), and BEST, programs that transferred to HHSC on September 1. HHSC has entered into a memorandum of understanding with TWC to continue the use of ReHabWorks by HHSC through August 31, 2017. However, a permanent solution is required.
Exceptional Item 45 Information Technology for Avatar
$6.1 million General Revenue
Avatar is the electronic medical record system used by the state mental health hospitals. If not funded, the state mental health hospitals would likely not be able to meet obligations for system support and would not function well enough to maintain certification.
- Exceptional Item 46 Information Technology for Electronic Life Record for Rio Grande State Center
$2 million General Revenue
The SSLC portion of Rio Grande State Center (RGSC) was not included in the transition to the new DADS SSLC Life Record. This exceptional item would fund installation and development of the ability to electronically exchange patient information between the other services co-located at RGSC.
Exceptional Item 47 Information Technology for State Mental Health Hospital Video Conferencing
$2 million General Revenue
This item would fund video conferencing technology infrastructure improvements in order to take advantage of telemedicine efficiencies.
Exceptional Item 48 Information Technology for Texas Integrated Eligibility Redesign System Transition
$12 million All Funds
This item would fund a six-month Texas Integrated Eligibility Redesign System (TIERS) contract transition to a possible new vendor. TIERS is HHSC’s service eligibility system.
Exceptional Item 49 Information Technology for Social Security Number Removal Initiative Medicare
$7.1 million All Funds
Exceptional Item 50 Information Technology for Legal Management System
$8.3 million All Funds
Exceptional Item 51 Information Technology for Cyber Security
$4.8 million All Funds
Exceptional Item 52 Information Technology for Data Center Services
$59.7 million All Funds
Exceptional Item 53 Information Technology for Non-DCS Hardware/Software Refresh
$43.6 million All Funds
Exceptional Item 54 Information Technology for Seat Management: PCs, laptops, servers
$7.1 million General Revenue, $7.4 million All Funds
Exceptional Item 55 Information Technology for Access Management
$2.7 million All Funds
Exceptional Item 56 Inspector General Staff of 18
$1.8 million All Funds
Exceptional Item 57 Information Technology for Inspector General Medicaid Fraud and Detection System
$5 million General Revenue, $20 million All Funds
Exceptional Item 58 Information Technology for Inspector General Case Management System
$2.5 million General Revenue, $5 million All Funds
Exceptional Item 59 Inspector General Background Check Staff of 14
$1.1 million All Funds
Exceptional Item 60 Texas Civil Commitment Office Caseload Growth
$5.1 million General Revenue, $5.1 million All Funds
This item would fund an expected increase of 749 people of locally prosecuted Sexually Violent Predators who will require treatment and supervision by the Texas Civil Commitment Office (TCCO).
Exceptional Item 61 Texas Civil Commitment Office Healthcare
$1.7 million General Revenue, $1.7 million All Funds
Exceptional Item 62 Texas Civil Commitment Office Supported Living
$1.6 million General Revenue, $1.6 million All Funds
Exceptional Item 63 Texas Civil Commitment Office 2% Contract Per Diem Increase
$627,000 General Revenue, $627,000 All Funds
Exceptional Item 64 Texas Civil Commitment Office Health Human Services Commission Oversight Costs
$213,000 General Revenue, $213,000 All Funds
10% Budget Reduction Options
A number of options were proposed for reducing the HHSC budget for FY 2018–2019 by 10%. Rate reductions make up about two-thirds of the 10% reduction options. Below are two of the options that, if passed by the Legislature, could impact people with IDD in Texas:
- Option 12 Program and Service Reductions
Totaling $20.6 million General Revenue
Little detail is provided in terms of the full impact, however, this item contains reductions to the following programs:
- $5.6 million General Revenue for Early Childhood Intervention
- $1.1 million General Revenue for Children’s Blind Services
- $1.4 million General Revenue for Autism Services
- $900,000 General Revenue for Independent Living Services
- $5 million General Revenue for Comprehensive Rehabilitation Services
- $78,000 General Revenue BEST
- $550,000 General Revenue Deaf and Hard of Hearing
Option 3 Rate Reductions
Totaling $291.2 million General Revenue, $359.7 million All Funds
The following programs could receive 8.2% rate reductions impacting client care: Community Attendant Services, Primary Home Care, nursing facilities, community-based intermediate care facilities, and developmental disabilities waivers.
TCDD Summary of HHSC LAR
(PDF, 13 pages, 306 KB)
Resumen de TCDD de la LAR del HHSC
(PDF, 15 pages, 525 KB)
- see the Texas HHSC Legislative Appropriations Request for Fiscal Years 2018–2019 Volume 1 PDF on the HHSC Fiscal Year 18–19 LAR HHSC Budget Planning webpage.