Compendium of Budget Information for the 2014 General Session
| Social Services Appropriations Subcommittee  (PDF) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Line Item: Services 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 intellectual disabilities 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 an Intellectual Disability (ICFs/ID) with funding through the Department of Health. Background Intermediate Care Facilities for People with an Intellectual Disability (ICFs/ID) The other system of providing Medicaid-supported services for individuals with disabilities is the mix of privately and publicly owned and operated ICFs/ID. Private institutions range in size from 12 beds to more than 80 beds. The ICF/ID system is funded through the Division of Medical and Healthcare Financing in the state Department of Health (Medicaid). The Utah State Developmental Center in American Fork, with a current population of 206 residents, is a state operated ICF/ID and is funded through DSPD. The ICF/ID system is approximately 70 percent financed with federal Medicaid funds. If qualified, patients have a right to be admitted to an ICF/ID. There cannot be a waiting list for ICF/ID services. Home and Community-based Services (HCBS) The state has also chosen to provide an alternative to the ICF/ID 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/ID, 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 the Division of Medical and Healthcare Financing of the state Department of Health which contracts with DSPD to operate certain of its HCBS waiver programs. This includes determining eligibility for services and serves as the gatekeeper for the HCBS systems. It is a Medicaid requirement that the health and safety service needs of individuals receiving services under the HCBS waiver be met. The Medicaid waiver requires a review of an individual's needs take place at least annually. Approximately 10 percent of individuals on the waiver are identified each year as having increased health and safety needs due to worsened conditions. 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. This list has grown from 498 in 1990 to 1,892 in 2013. The number of people served since 1990 has grown from 1,989 to 4,797, which is a 141 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 natural 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 (DCFS) and Juvenile Justice Services are also required to be served by DSPD. In FY 2013 the total number was 32. When these youth become adults they age out of DCFS custody and lose the funding previously provided for them as the funding stays with DCFS to pay for new children and youth with intellectual disabilities placed in state custody. As a condition of the federal waiver approval, Utah agrees not to drop current waiver recipients from service (State Medicaid Directors Letter -- Olmstead Update No. 4). Portability between ICFs/ID and Home and Community-based Services In 1998, legislation set in motion a process where individuals with developmental disabilities and/or intellectual disabilities who are receiving state services could move from institutional care (ICFs/ID) to Home and Community-based Services (HCBS), or the reverse. Since FY 2005, approximately 60 people have moved from the ICFs/ID 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/ID clients, to DSPD, which funds the community services program. After several years of experience, it was observed that as individuals transferred out of ICFs/ID, 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. The ICF/ID industry occupancy is consistently at 99 percent. UCA 26-18-503, Authorization to Renew, Transfer or increase Medicaid Certified Programs, authorizes the Medicaid director to consider how to add additional capacity to the long-term care delivery system to best meet the needs of Medicaid recipients. Over the years, Medicaid has managed service capacity for this population through a balanced approach of adding capacity to both facility based and community based services. For facility based services, a limited number of additional ICF/ID beds has been authorized. For community based services, a factor has been added to Medicaid's Case Load and Utilization line item to allow a limited number of individuals to transfer from ICFs/ID into the Community Supports Waiver. Statutory Authority Utah Code Title 62A, chapters 5, 5a, 5b, and 6 describe the state's program of services for people with disabilities.
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 a person with a disability. In addition to state law, many functions provided by DSPD have provisions detailed in federal law. Those federal law references, where available, follow:
Intent Language The Legislature intends the Division of Services for People with Disabilities (DSPD) use FY 2014 beginning nonlapsing funds to provide services for individuals needing emergency services, individuals needing additional waiver services, individuals who turn 18 years old and leave state custody from the divisions of Child and Family Services and Juvenile Justice Services, and individuals court ordered into DSPD services. The Legislature further intends DSPD report to the Office of the Legislative Fiscal Analyst on the use of these nonlapsing funds. Performance During the 2013 General Session of the Legislature, Services for People with Disabilities -- Performance Measures was presented showing an eight year history of DSPD output and outcome measures. An update of these output and outcome measures will be provided during the 2014 General Session of the Legislature. Related Material Human Services Technology Services FY 2014 Plan Issue Brief - 2014 General Session - Services for People with Disabilities Performance Measures Issue Brief - 2014 General Session - S.B. 259 Amendments to Disability Waiting List Budget Estimates for DSPD Mandated Additional Needs Budget Estimates for Persons Aging OUt of DCFS Court Ordered Services FY 2015 Budget Estimates for Disabilities Waiting List Contract Provider COLA FY 2015 FY 2015 Budget Estimates for DSPD Mandated Additional Needs FY 2015 Budget Estimates for Persons Aging Out of DCFS Funding Detail Medical and Health Care Financing - Medicaid Utah's Medicaid agency is the Division of Medical and Healthcare Financing (DMHF) 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) waivers, 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. DMHF also contracts with and provides administrative oversight for private Intermediate Care Facilities for people with an Intellectual Disability (ICFs/ID). 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 (UCA 62A-5-102(7)). 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 has been annually reviewed and then renewed through adoption of intent language. Utah State Developmental Center Land Fund -- Restricted Special Revenue Fund In 1995, the Legislature created the Account for People with Disabilities (UCA 63A-5-220) and renamed the account the Utah State Developmental Center Land Fund in 2013. The fund consists 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 department may only use interest earned on the fund itself. After approval by the division director in consultation with the department executive director, these funds may be used for the benefit of the Utah State Developmental Center and programs described in Title 62A, Chapter 5, which is the DSPD section of the code. For analysis of current budget requests and discussion of issues related to this budget click here.
Program: Administration - DSPD 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. Funding Detail
Function The division operates with a single region spanning the state for service delivery. The regional service delivery staff provides coordination for service recipients. The region is the point of entry for people seeking services from the division. The region contracts for services with private providers and oversees and evaluates 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 Individuals with an Intellectual Disability (ICF/ID). 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 206 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 Center's care delivery system, 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
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/ID. 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 $30.16 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 Utah State Office of Rehabilitation 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 $6,373. 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. 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 for ongoing expenditures by the Legislature.
Program: Acquired Brain Injury Waiver Function The Acquired 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 Disabilities 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 $656 and $2,746 to people with severe physical disabilities involving the loss of the use of two or more limbs that are able to live independently with the aid of a personal attendant. Without this assistance, they would likely be in a nursing home. Each service plan 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 867 individuals have moved from non-waiver to waiver (Medicaid) funding. In FY 2013, there were 95 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. Funding Detail
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COBI contains unaudited data as presented to the Legislature by state agencies at the time of publication. For audited financial data see the State of Utah's Comprehensive Annual Financial Reports.