Compendium of Budget Information for the 2009 General Session
| Health & Human Services Appropriations Subcommittee | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Subcommittee Table of Contents | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Group: Health & Human Services - Department of Human Services Line Item: Svcs for People w/Disabilities Function The Division of Services for People with Disabilities (DSPD) is responsible for providing residential, day services, family support services, and attendant care for people with severe mental retardation and other related conditions, including brain injury and physical disabilities. To receive services, people must have substantial functional limitations in three or more of the following life activities: self care, receptive and expressive language, learning, mobility, self direction, capacity for independent living, or economic self-sufficiency. The services provided range from limited family support to a full array of 24-hour services both in the community and at the Utah State Developmental Center. Services are also available in private Intermediate Care Facilities for people with Mental Retardation (ICFs/MR) with funding through the Department of Health. Background Intermediate Care Facilities for People with Mental Retardation (ICFs/MR) The other system of providing Medicaid-supported services for individuals with disabilities is the mix of privately and publicly owned and operated ICFs/MR. Private institutions range in size from 15 beds to more than 80 beds. The ICF/MR system is funded through the Division of Health Care Finance in the state Department of Health. The Utah State Developmental Center in American Fork, with a current population of 235 residents, is a state operated ICF/MR and is funded through DSPD. The ICF/MR system is approximately 70 percent financed with federal Medicaid funds. If qualified, patients have a right to be admitted to an ICF/MR. There cannot be a waiting list. Home- and Community-based Services (HBCS) The state has also chosen to provide an alternative to the ICF/MR system, which is the Home- and Community-based Services (HCBS) system. The HCBS system includes a range of services and supports for individuals in homes and apartments, including full residential placement arrangements, located in community settings throughout the state. This system is also 70 percent funded by Medicaid as a result of being a Medicaid waiver program. Unlike ICFs/MR, this service is not an entitlement to eligible individuals, but can only be used to the extent that resources permit. Therefore, most states have waiting lists for services in their HCBS programs. The HCBS system is funded through DSPD, which determines eligibility for services and serves as the gatekeeper in both the ICFs/MR and the HCBS systems. Waiting List for Home and Community Based Services There are more eligible people desiring home- and community-based services under the Medicaid waiver than there are resources available. This has caused a waiting list. DSPD has a current list of 1,675 individuals waiting for services. This list has grown from 498 in 1990 to 1,675 in 2008. The number of people served since 1990 has grown from 1,989 to 4,834, which is a 243 percent increase. Emergency Services Each year, there are emergencies requiring immediate assistance from the division. A crisis may arise when persons with disabilities grow older and develop behavior problems or when caretakers become ill or die. A crisis may also arise in cases where individuals are committed to division services by the courts. Children aging out of state custody in the divisions of Child and Family Services and Juvenile Justice Services are also required to be served by DSPD. The division typically spends an additional $800,000 to $1,400,000 each year for these emergency services needs. Portability between ICFs/MR and Home- and Community-based Services In 1998, legislation set in motion a process where individuals with developmental disabilities and/or mental retardation who are receiving state services could move from institutional care (ICFs/MR) to Home- and Community-based Services (HCBS), or the reverse. Since FY 2000, approximately 85 people have moved from the ICFs/MR system to services in the community. It was originally agreed that to facilitate these moves, state funds would also be transferred from the Department of Health, which funds ICFs/MR clients, to DSPD, which funds the community services program. After several years of experience, it was observed that as individuals transferred out of ICFs/MR, new clients soon entered the system and filled the vacated beds. This added cost prevented the Department of Health from shifting any additional funds to DSPD for clients transferred to the community waiver services. Therefore, a moratorium was placed on further portability transfers in FY 2003. In FY 2005, the Legislature appropriated new funding for portability to the Department of Health which allowed for some individuals to transfer to community service. Since that time, additional appropriations to allow portability have been inconsistent. Statutory Authority Utah Code Title 62A, chapters 5, 5a, 5b, and 6 describe the state's program of services for people with disabilities. Chapter 5:
Chapter 5a: creates the Coordinating Council for Persons with Disabilities. Chapter 5b: sets out rights and privileges of a person with a disability Chapter 6: deals with sterilization of handicapped persons. Intent Language
Agency Response: The division expects to spend $1,117,800 of this nonlapsing amount during FY2009 for the purposes listed in the legislative intent language.
Agency Response: The Division of Services for People with Disabilities has set aside $40,000 to contract with a fiscal intermediary to receive time sheets and other requests for disabilities respite services. This represents 16 percent of the $250,000 appropriated by the Legislature for disabilities respite care. The division was able to obtain funds from the Utah Council for People with Disabilities to pay most of the cost of training for those who will receive respite services through this program. The remainder, which represents the General Fund match for the funding, will be paid from the appropriation in the amount of $3,324 or 1.33 percent of the appropriation. Background checks have cost $140 which is.06 percent of the appropriation. The total oversight cost associated with the disabilities respite funds is $43,460, or 17.4 percent of the appropriation. There will be more costs for background checks, but we do not expect those costs to exceed $3,000. The contract with the fiscal agent was finalized effective September 1, 2008. The training contract, aimed at preparing participant households to become employers for respite service staff, was awarded effective August 25, 2008. Subsequently, training has been provided in several different locations throughout the state. To date, 250 households have enrolled in the service with a budget of $800 per household. So far, DSPD has been billed $720 for 82 hours of services for the participating households. Due to the need to contract the training and fiscal intermediary services, and the time it takes for background checks, the actual provision of services is only just getting started. The division will have updated information for the upcoming Legislative session. Funding Detail The division has statutory non-lapsing authority and will typically have some amount shown in Beginning Nonlapsing. The statute restricts use of nonlapsing funds for one-time purposes unless authorized by the Legislature. Health Care Financing - Medicaid Utah's Medicaid agency is the Division of Health Care Financing (HCF) in the Department of Health. This agency coordinates with DSPD to establish rates and eligibility, prepare revisions and renewals of Utah's Home- and Community-based Services (HCBS) Waiver, process reimbursements for Medicaid funds, and train and monitor for compliance. DSPD administers three HCBS waivers: 1) Community Supports, 2) Acquired Brain Injury, and 3) Physical Disabilities. HCF also contracts with and provides administrative oversight for private Intermediate Care Facilities for people with Mental Retardation (ICFs/MR). Non-Lapsing Authority and Attrition DSPD has nonlapsing authority to carry any unused funds from one fiscal year into the subsequent fiscal year. These funds can only be used for one-time expenditures unless otherwise authorized by the Legislature. Nonlapsing balances are often created because DSPD generates savings through attrition when individuals receiving services exit the program. Attrition can occur when an individual moves out of state or relocates into institutional care, the individual dies, or the individual no longer meets the eligibility requirements. The 2004 Legislature approved a plan to allow the use of nonlapsing funds to cover ongoing costs associated with emergency services and individuals who age out of foster care with the understanding that internal savings will generate the ongoing base funds needed to continue their services in future years. This authority is annually renewed through adoption of intent language. Trust Fund for People with Disabilities - General Fund Restricted In 1995, the Legislature created a Trust Fund for People with Disabilities (UCA 63A-5-220) consisting of proceeds from the sale or lease of lands and facilities at the Utah State Developmental Center (USDC) located in American Fork. By statute, the Legislature may only appropriate lease or rental receipts or interest earned on the fund itself. After approval by the Board of Services for People with Disabilities, these funds may be used for programs described in Title 62A, Chapter 5, which is the DSPD section of the code.
Function The State Administration Office provides policy development, quality assurance, general management, and budget and fiscal oversight for the state operated support coordination system, also known as the case management system. In addition, this office contracts for private and public service providers. They also oversee the Utah State Developmental Center at American Fork. The office also develops policy recommendations for the Board of Services for People with Disabilities. Funding Detail
Function The division has divided the state into three regions for service delivery. The regional service delivery staff provides coordination for service recipients. The regions are the point of entry for people seeking services from the division. The regions contract for services with private providers and oversee and evaluate the quality of services delivered. Funding Detail
Program: Utah State Developmental Center Function The Utah State Developmental Center (USDC), formerly known as the Utah State Training School, is a publicly funded and managed Intermediate Care Facility for persons with Mental Retardation (ICF/MR). The center provides 24-hour residential and active treatment services. Specialized services include: medical and dental services; physical, occupational, speech, and recreational therapy; psychological services; social work; and day training. In December of 1989, a class action lawsuit, known by the title of Lisa P., was filed against the state by the Disability Law Center and the Association of Retarded Citizens (ARC) of Utah on behalf of all residents of the USDC. A settlement agreement was entered into in October of 1993 that required an evaluation of each resident to determine appropriate placement. Due in large measure to the terms of the settlement agreement, USDC has seen its population decrease from about 425 in 1991 to 237 today. The Developmental Center has restructured its delivery system. This has involved remodeling many of its dormitory-type housing units into apartments with one to three bedrooms which has provided more independence and privacy for its residents. This has altered the care delivery system at the center, requiring a greater staff-to-client ratio. This has served to decrease the behavior problems of residents and improve their quality of life. Funding Detail During FY 2005, the Developmental Center reduced the motor pool by 12 vehicles. Six of the twelve vehicles were replaced with Kawasaki Mules to be used for grounds work. It was also determined that the other six vehicles did not need to be replaced.
Program: Community Supports Waiver Function The Community Supports (Medicaid Home- and Community-based Services) Waiver allows states to provide services to individuals using Medicaid funds outside of standard institutional programs. Participants must be qualified for admission to an institution such as an ICF/MR. Assistance that may be provided under the waiver program includes a multitude of services ranging from family support to 24-hour residential care. Residential Services include five basic models which fall under two broad categories: 1) supported living and 2) supervised living.
Day Services programs take place in the community or in workshops and are designed to provide work opportunities as well as maintain skills in post-school years. Supported Employment programs place people with disabilities in jobs in regular work environments. A job coach is assigned for each person to provide on-the-job training and to help solve problems that may arise. The cost of supported employment is $33.84 per job coach hour. In some cases, individuals are able to reduce the need for a job coach and may eventually handle a job on their own. For most individuals who enter this service, the Office of Rehabilitative Services in the State Office of Education funds the first 170 hours of training and the Division of Services for People with Disabilities provides the ongoing funding. Family Support provides services to families that enable them to care for their children with disabilities at home. These services are provided through contract providers or by staff hired directly by parents. The individualized nature of the program does not allow for fixed rates or funding allocations. The annual average expenditure per consumer is about $5,957. Transportation Services helps people with disabilities in getting from their homes to day programs, jobs, and other activities. The need for transportation assistance and the cost of transporting people is one of the most frequently mentioned issues when public hearings are held on services for people with disabilities. This is especially true in the rural areas of the state. In 2008, 2,345 people received transportation services. Funding Detail The division has statutory authority to not lapse funds at the end of a fiscal year and will typically have some amount of Beginning Nonlapsing balance available. The statute restricts use of nonlapsing funds for one-time purposes unless authorized by the Legislature.
Function The Brain Injury Home- and Community-based Services Waiver is for people who have a documented brain injury, are 18 years of age or older, and require the level of care provided in a nursing facility. The waiver allows the use of Medicaid funds outside of institutional settings. Services provided under this waiver include:
Funding Detail
Program: Physical Disability Waiver Function The Physical Disabilities Home- and Community-based Services Waiver is also a Medicaid waiver program allowing the use of Medicaid funds outside of the standard institutional setting. The Physical Disabilities Waiver provides monthly expenditure allocations between $671 and $2,411 to people with severe physical disabilities who are able to live independently with the aid of a personal attendant. Without this assistance, they would likely be in a nursing home. Each grant is based on the level of care required by the person. The person is responsible for hiring, training, and supervising the attendant. An intermediate organization handles payment and other payroll functions necessary in connection with individuals hired by service recipients. Funding Detail
Function Non-waiver Services includes services provided to individuals who are not eligible for any of the Medicaid waivers due to either income and asset issues or the nature of the disability. Non-waiver Services also includes non-Medicaid eligible services provided to individuals in the waiver program, such as psychological assessments used to determine eligibility, residential start-up costs, housing assistance, and special needs funding. These expenditures do not draw down matching Medicaid funds. Efforts to Limit Expenditures in this Service Category There has been a concerted effort to qualify and move individuals from this state-funded-only program over to the Medicaid waiver program. Since 1999, over 720 individuals have moved from non-waiver to waiver (Medicaid) funding. In FY 2008, there were 271 people remaining in this program. Some individuals receiving services under this program would qualify for Medicaid but refuse to either apply for Medicaid or spend down their income and assets in order to qualify. These individuals have had their service funding reduced to a commensurate level that the state would provide under the waiver program. Individuals who do not meet the waiver level of care requirements must submit a Graduated Fee Assessment Form to the division. Based on the fee assessment, 11 non-waiver individuals paid a monthly fee in FY 2008 which generated $11,484. Funding Detail The state portion was reduced during the 2008 Second Special Session of the Legislature.
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