COBI 2015 - Home and Community Based Waiver Services

Overview
Issues
Background
Financials

Sources Uses

FY 2016 Appropriation

Medicaid clients must meet nursing facility level of care as described in Administrative Rule R414.502 in order to be eligible for the Home and Community Based Waiver Services. Clients must meet two of the following three conditions: (1) require substantial physical assistance for activities of daily living, (2) certain level of dysfunction in cognition, and (3) a less structured setting cannot meet the level of care needed.

Funding History

Appropriation Overview

During the 2015 General Session, the Legislature appropriated for Fiscal Year 2016, $217,842,000 from all sources for Home and Community Based Waiver Services. This is a 3.7 percent increase from Fiscal Year 2015 revised estimated amounts from all sources. The total includes $4,722,800 in new approprations from the General/Education Funds.

Appropriation Adjustments

The following appropriation adjustments were made during the 2015 General Session:

DescriptionOngoingOne-Time Medicaid Caseload Reduction$0 ($1,600,000)

OngoingOne-TimeFinancing Source

$0 ($1,600,000)General Fund, One-time

The following areas create costs for the state in Medicaid in FY 2016: (1) estimated increase of 1,900 or 1% clients in FY 2016, (2) $3.9 million for a 2% projected increase in accountable care organization contracts starting in January 2016, (3) $3.0 million for a new federal regulation to provide autism spectrum disorder-related services when medically necessary up to age 21, and (4) $3.1 million for cost increases over which the state has no control due to federal regulation or has opted not to exercise more state control. FY 2014 ended and FY 2015 will likely end under budget which reduces the baseline costs for FY 2016.

Pilot Program for Assistance for Children with Disabilities and Complex Medical Conditions$0$10,835,600

OngoingOne-TimeFinancing Source

$0$3,216,000General Fund, One-time

$0$7,619,600Federal Funds

"This bill directs the Department of Health to apply for a Medicaid waiver for children with disabilities and complex medical conditions." How Measure Success? "Waiver services will be less costly than costs that would have been incurred if the child was served in a nursing facility." Fiscal Note: $3,333,600 ongoing; ($940,100) one-time GF

Technology Dependent Waiver Capacity Expansion$1,054,900$0

OngoingOne-TimeFinancing Source

$313,100$0General Fund

$741,800$0Federal Funds

this will fund 10 of the 75 Medicaid individuals on the waiting list for this waiver. The 10 to be served are chosen based on severity of needs and duration of time on the waiting list. The Department of Health indicates that these individuals are being served currently in higher cost settings and are not all on Medicaid, but there will be no savings from expanding the waiver as the agency estimates new individuals to take up the higher cost settings freed up by new waiver clients. The waiver currently serves about 110 individuals. The waiver allows parental income to be excluded when determining an individual's eligibility for Medicaid. About 75% of the 10 individual's costs will be for regular Medicaid services and 25% for the waiver costs. How Measure Success? Count and cost of new individuals enrolled (via annual cost effectiveness report to federal government).

The State has seven home and community based waiver programs. Two are administered directly by the Utah Department of Health (Waiver for Children who are Technology Dependent and the New Choices Waiver). Four are administered by the Division of Services for People with Disabilities in the Department of Human Services (Acquired Brain Injury Waiver, Community Supports Waiver for Individuals with Intellectual Disabilities and Other Related Conditions, the Waiver for Individuals with Physical Disabilities, and the Autism Waiver). One is administered by the Division of Aging and Adult Services in the Department of Human Services (Waiver for Individuals Aged 65 and Older).

The Department of Health is appropriated State General Funds for the two waivers it oversees directly as well as the Autism Waiver. The Department of Human Services is appropriated State General Funds for the four waivers that it oversees.

The federal government must specifically approve all waiver programs. One criteria for approval requires that waiver services cost less than or equal to the cost of services in an institutional setting. The waivers can offer new or expanded benefits to specific groups of individuals in exchange for reducing or maintaining overall costs to the program.

New Choices Waiver

The goal of the New Choices Waiver is to move clients out of nursing homes into home and community based services. In addition to the normal Medicaid requirements to receive nursing home services, a client must have been living in a nursing home a minimum of 90 days to qualify for this waiver. The waiver serves up to 1,700 clients. This program is possible because of special federal authority granted via a 1915C waiver.

Autism Waiver

The Autism Waiver provides proven effective services for children between the ages of two to six with autism spectrum disorder. The waiver serves up to 300 children. The Department of Human Services administers the waiver. This program is possible because of special federal authority granted via a 1915C waiver.

Waiver for Children who are Technology Dependent

The Waiver for Children who are Technology Dependent serves medically fragile children, who are technology dependent. Without this waiver nursing homes would serve these children. The waiver serves up to 120 clients. This program is possible because of special federal authority granted via a 1915C waiver.

Intent Language

SB0002: Item 75

The Legislature intends that with the funding appropriated for the building block titled, "Intermediate Care Facilities - Intellectually Disabled," the Department of Health shall: 1) Direct funds to increase the salaries of direct care workers; 2) Increase only those rates which include a direct care service component, including respite; 3) Monitor providers to ensure that all funds appropriated are applied to direct care worker wages and that none of the funding goes to administrative functions or provider profits; In conjunction with Intermediate Care Facilities - Intellectually Disabled providers, report to the Office of the Legislature Fiscal Analyst no later than September 1, 2015 regarding: 1) the implementation and status of increasing salaries for direct care workers, 2) a detailed explanation with supporting documentation of how Intermediate Care Facilities - Intellectually Disabled providers are reimbursed, including all accounting codes used and the previous and current rates for each accounting code, and 3) a conceptual explanation of how Intermediate Care Facilities - Intellectually Disabled providers realize profit within the closed market of providing Intermediate Care Facilities - Intellectually Disabled services.

SB0002: Item 75

The Legislature intends that, if funds are available, Medicaid fee-for-service payments for anesthesia services be increased from the current amount of $18.27 to $23.73 for Fiscal Year 2016.

SB0002: Item 75

The Legislature intends that 5% of all funds provided in the Medicaid program for managed care dental plans be used for contracted plan administration and that any funds provided for the Affordable are Act premium tax not be included in that 5% administrative funds amount.

SB0003: Item 123

Under Section 63J-1-603 of the Utah Code the Legislature intends that up to $3,216,000 of the appropriations provided for the Medicaid Optional Services line item not lapse at the close of Fiscal Year 2016. The use of any nonlapsing funds is limited to a pilot program for assistance for children with disabilities and complex medical conditions to be used in similar amounts over three years with the goal of serving a similar number of clients over three years.

SB0007S01: Item 6

The Legislature intends that the Department of Health report on the following performance measures for the Medicaid Optional Services line item: (1) annual state general funds saved through preferred drug list (Target = $8.5 million general fund or more), (2) count of new choices waiver clients coming out of nursing homes into community based care (Target = 390 or more), and (3) emergency dental program savings (Target = $250,000 General Fund savings or more) by January 1, 2016 to the Social Services Appropriations Subcommittee.

SB0007S01: Item 18

The monthly caseload is the number of clients served on waivers.

Display By:

Funding Source

Expenditure Category

Appropriation Type:

Appropriation History by

Sources of Finance	FY11 Actual	FY12 Actual	FY13 Actual	FY14 Actual	FY15 Approp	FY15 Change	FY15 Revised	FY16 Change	FY16 Approp
General Fund	2,232,600	1,042,900	24,400	1,033,100	1,859,200	(259,500)	1,599,700	(92,900)	1,506,800
General Fund, One-time	(2,084,700)	0	0	(2,999,800)	300	(1,600,000)	(1,599,700)	4,815,700	3,216,000
Federal Funds	121,852,000	115,527,400	122,398,800	130,313,800	141,915,900	6,592,300	148,508,200	4,827,500	153,335,700
American Recovery and Reinvestment Act	(2,800)	0	0	0	0	0	0	0	0
Transfers - Medicaid - DHS	35,764,100	47,595,200	52,811,000	53,328,400	58,537,800	3,028,000	61,565,800	(1,782,300)	59,783,500
Beginning Nonlapsing	0	0	4,203,800	4,058,100	0	0	0	0	0
Closing Nonlapsing	0	0	(4,058,100)	0	0	0	0	0	0
Lapsing Balance	0	0	0	(4,700)	0	0	0	0	0
Total	$157,761,200	$164,165,500	$175,379,900	$185,728,900	$202,313,200	$7,760,800	$210,074,000	$7,768,000	$217,842,000

Categories of Expenditure	FY11 Actual	FY12 Actual	FY13 Actual	FY14 Actual	FY15 Approp	FY15 Change	FY15 Revised	FY16 Change	FY16 Approp
Personnel Services	0	11,400	42,400	69,900	600	144,000	144,600	5,200	149,800
Current Expense	0	0	2,400	1,200	0	1,200	1,200	0	1,200
DP Current Expense	0	0	1,600	600	0	600	600	0	600
Other Charges/Pass Thru	157,761,200	164,154,100	175,333,500	185,657,200	202,312,600	7,615,000	209,927,600	7,762,800	217,690,400
Total	$157,761,200	$164,165,500	$175,379,900	$185,728,900	$202,313,200	$7,760,800	$210,074,000	$7,768,000	$217,842,000

Show Table | Show Additional Information

Other Indicators	FY11 Actual	FY12 Actual	FY13 Actual	FY14 Actual	FY15 Change	FY15 Revised	FY16 Approp
Budgeted FTE	0	0	0	1	2	2	2
Actual FTE	0	0.20	0.60	0.80	0	0	0
Monthly Caseload	5,849	6,094	6,351	6,778	0	0	0

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.