Public Comment — IDD Managed Care Pilot

TCDD Letterhead

Public Comment
Senate Bill 7 Service Delivery Model Pilot
January 22, 2016

Thank you for the opportunity to provide comments on the pilot project required by Senate Bill 7 (2013) and House Bill 3523 (2015) to test one or more service delivery models involving a managed care strategy based on capitation to deliver long-term services and supports under the Medicaid program to individuals with intellectual and developmental disabilities. TCDD is established by state and federal law and is governed by 27 board members, appointed by the Governor, 60% of whom are individuals with developmental disabilities or family members of individuals with disabilities. TCDD’s purpose in law is to encourage policy change so that people with disabilities have opportunities to be fully included in their communities and exercise control over their own lives.

Managed Care and IDD
Broadly, our concerns remain regarding managed care organizations’ ability to assist people with IDD. A recent HHSC legislative report, Utilization Review In STAR+PLUS Medicaid Managed Care, identified the broad failure of MCO service coordinators to understand the purpose of one of the required assessments to the extent that skilled nursing needs were not appropriately addressed in the development of individual service plans. If people in the STAR+PLUS waiver program cannot get their skilled nursing needs met, we strongly question whether habilitation needs will be adequately assessed or appreciated by MCO service coordinators. In fact, at a recent Promoting Independence Advisory Committee meeting, it was implied that if a person’s condition did not improve that habilitation hours could be cut. Ensuring an emphasis on access to services to support community integration and employment seems daunting in a system struggling to ensure nursing needs are met.

Maintain Services
TCDD does not support managed care pilots unless it is clear that participants will receive all of the services and supports for which they are eligible in the arrangement. If implemented, the model should include an external advocacy component to ensure accountability and timely dispute resolution. The aforementioned report on utilization review further validates our concerns about access to care and other contract compliance issues. A pilot would require a coordinated process to address and facilitate follow-up action on contract compliance and MCO process issues specific to addressing timely and adequate response to members’ needs, change in health status, seamless care coordination, continuity of care, and ensuring that the skilled nursing and habilitation needs of members are appropriately assessed and met.

Participant Compensation
The pilot should include an adequate number of participants to support replication recommendations. Participation must be voluntary. To attract participants, they should be compensated for taking the risk and providing the state with the information it needs for future planning.

Strategic Coordination
Texas is in the process of developing a statewide transition plan to come into compliance with the Center for Medicare and Medicaid Services (CMS) Home and Community Based Services (HCBS) Settings Rule. HCBS Settings Rule compliance involves the remediation of an array of Medicaid funded services that will be an ongoing long-term process that will require significant resources. Therefore, HCBS Settings Rule compliance strategies should be tested in concert with any new managed care strategies. In providing community based services, developing the state’s ability to provide for a meaningful day that is not predicated on day habilitation programs should be prioritized. To that end, TCDD recommends that employment should be every pilot participant’s first assumed day outcome, in accordance with Texas’ Employment First policy required by SB 1226 (2013). If a person declines to be employed or requires employment assistance for a period of time to become employed, the pilot should test consumer direction of day habilitation funds such that up to four participants have the opportunity to combine/pool their resources to plan their own support for a meaningful day. In addition to shared staff, the pilot should test public private partnerships to develop cross-system collaborations so that people with disabilities have meaningful access to the same opportunities as their peers without disabilities including access to recreation and community centers, adult learning, and volunteer opportunities that are truly based on individuals’ interests.

Improvement Opportunities
This pilot is an opportunity to test truly person centered approaches to providing services that meaningfully include people with developmental disabilities in the design and implementation of their services. Thus, an applicant’s qualifications should largely be based on the extent to which people with DD are included in the strategy’s design and implementation. Pilot features should include the following.

  • A consumer oversight committee with the requisite supports to ensure meaningful input, including personal assistance, habilitation, and job coaches if necessary.
  • Formal peer to peer supports so that people with DD are paid to support their peers to lead their person directed planning process, and develop their own individual care plans and implementation plans so they truly reflect the individual’s desired goals and objectives.
  • Access to crisis respite services, like those used by the START programs in Tarrant, El Paso and Travis Counties.
  • Minimum training requirements for all workers that include the Institute for Person Centered Practice’s Person Centered Thinking Training, positive behavior interventions and supports and trauma informed care.

Direct Care Workforce
Although the pilot is specific to the system of services for persons with intellectual and developmental disabilities, the state must recognize that the broader system cannot be maintained a strong direct support workforce. The pilot should require an adequate living wage for direct support workers. It is also an opportunity to respond directly to advocates’ requests for data collection mechanisms in a pilot before rolling out broad implementation. The National Direct Service Workforce Resource Center recommended the following six workforce data components: (1) number of full-time workers; (2) number of part-time workers; (3) turnover rate; (4) vacancy rate; (5) average hourly wage; and (6) benefits (health insurance and paid time off).

Consumer Controlled Housing
TCDD supports piloting managed care strategies that reduce reliance on provider controlled housing and provide incentives that encourage consumer controlled housing. Such a system would empower people with IDD by ensuring that they have the support necessary to make informed choices about their housing options. There are a number of housing options that maximize independence and are affordable to people on SSI, including Section 8 Housing Choice Vouchers, the Project Access Program, and Section 811. TCDD supports housing options that are fully integrated in the community, in close proximity to goods and services and do not take the system backwards by perpetuating congregate living environments no matter how well intentioned. TCDD does not support including larger residential options in a managed care pilot. TCDD recommends that independent living, consumer direction, and employment are the first options offered in any pilot design.

Whole System Approach
We continue to believe that a pilot should include the whole system that serves persons with IDD, including all institutions and all waivers for which persons with IDD are eligible. This is particularly important because the Department of Aging and Disability Services is in the process of allowing state supported living centers to bill for services provided to community based waiver participants. In order to realize significant cost efficiencies, the most expensive services (institutional services) must be included in the pilot.

Role of Local Authorities
TCDD recommends that the role of the local authority be maintained in any pilot. Local authorities are responsive to their local communities and have access to local resources. Without a central role for local authorities, the system’s ability to leverage local resources could be limited significantly. We believe the local authorities’ role in providing independent service coordination and advocating for HCS participants has been valuable and has resulted in increased quality for those individuals. Continuing to insert and remove local authorities from the system will only undermine the system’s stability.

Finally, the system continues to be severely underfunded. Texas ranks 50th in statewide per person community spending. An honest dialogue about building community capacity and about the true cost of service provision to ensure a successful pilot and strong long term services and supports system is needed.

Respectfully submitted,


Jessica Ramos
Public Policy Director