Update: Intensive In-Home Autism Services

Jan Serak, ASW/ASSEW Legislative Chair

Autism Coalition – 1/12/04 Meeting Notes

Present: Lynn Breedlove, Liz Hecht, Jan Serak; about 32 parents, providers & disability advocates; and
DHFS staff (Beth Wroblewski, Julie Bryda, Morton Groves and Marge Pfiffer)

DHFS Update – Beth Wroblewski

Waiver started January 1, 2004

all county contacts are listed on website: www.dhfs.wisconsin.gov/bdds/autism
Beth & Julie contacted every county last week: more counties added (Wood) or considering to implement waiver (Jefferson, Washington, Racine & Outagamie)
If a family has not been contacted yet, email Beth Wroblewski: wroblm@dhfs.state.wi.us

“Family-Directed Option”

a short-term solution (as, for some of ABC clients unable to get a provider)
Fiscal intermediary packet – on DHFS website & mailed to some families
fiscal intermediary – does payroll (county charge is $15/payroll, not per check; if state administering program, state will not charge a payroll fee, as they will use the county Administrative Fee
need certified supervisor; in counties that state has responsibility, state will set up an arrangement certified people to do the supervision

Eligibility– kids automatically put on waiver list if “paid claims” and approved PA in effect Dec. 2003
DHFS will meet with every provider individually 1/12 – 1/23 to discuss client list, answer questions

hours DHFS allotted were 20 – 35/week (if client was <20 including travel + face-to-face treatment, brought up to 20 hours; but limited top end to 35 hours, so not include travel)
DHFS will review each child separately
DHFS willing to have “variables” to waiver for travel, as for remote rural locations; but unable to move all intensive phase kids to 35 hours
P.O. system now in place for providers in state-administered counties

Flexibility of hours under waiver

Ex: if child only uses 90% of services in 1 month, provider will still be paid 100%, so provider can count on consistent income; except if family on vacation, not pay provider then; Providers are paid in advance, so next payment to provider would be less for that month.

Waiver is for full year (52 weeks)

But, DHFS contracts with counties are “loaded” at 45-47 weeks, based paid claims data.
Easier for DHFS to add $ to the county than deal with overpayment
Kristy Pomeraning, DHFS contact to best answer fiscal questions

Administrative fees & Case management fees

Intensive – rate to provider is separate from any fees
Post-Intensive – rate comes out of the $30.60/day; county fees must be their “Actual Cost” for service coordination & administration; Admin. Fee is capped at 7% (counties charging 5 – 7%); Service Coordination fee is based on their hourly rate for the Service Coord. staff.
Actual Cost – county must be able to substantiate “Actuals” (ie, time sheets, travel records); parent may ask for records; staff can count travel to/from home

“Waiver of Contact”

parent can sign a “waiver of contact” for no case management beyond the minimum federal requirements - if #1 and #2 below are completed
federal Medicaid waivers require: annual in-home visit with child present [purpose: 1) assessment/verify Katie Beckett eligibility; 2) write service plan]; and at least one 6 month check-in (parent can go to county office to save staff hours/child not need to be present for check-ins).

Can children switch providers within the waiver?

Yes, families have freedom of choice under the waiver
But, due to “contractual issues”, notice is required (provider has county contract for a month with 2 week to 30 day notice required)

Will ABC families lose intensive hours?

Many intensive kids have been put on “waiting lists” by other providers
If families continue to use their waiver budget (as, for Family-directed services) & at intensive rate, hours will count as being used (as, towards their 3 –year allotment)
If no funds used, or if only using post-intensive level hours, families will be credited 1 – 2 months of services

Kenosha & Milwaukee Counties – starting an organization for people who could be lead therapists
What about the 250 New Kid waiver slots?

DHFS does not currently know the # of available slots – they think they will know by March
DHFS must “make sure they can make a 3-year financial commitment”, so still have to determine budget used up since July 1 & projected after all provider contracts done in January
DHFS will send Clarification of the Intake Process to counties:
New kids must have: 1) Level of care assessment – state Katie Beckett consultant 2) Diagnosis in Autism Spectrum (by qualified person/not educational dx @ school), this can be done by a provider, but eventually will be “Independent Assessment” process

County notifies state, state puts child on waiver waiting list (or if state run, then call Julie Bryda)
Some providers have New Kids ready to go (KB assessment & Diagnosis done)
DHFS said that if a child does not get started by 8 and is in the pipeline now, they will work with providers to make an exception to start
Some ABC clients “jumping over” kids on waiting list of other providers

Other funds

Can only be on one waiver at once
CIP, CSLA, other waiver – if child receiving service previous to start of the Children’s waiver; county MUST keep commitment & ADD former waiver $$ to Plan on top of autism treatment hours.
Family Support Funds

will also be ADDED to Service Plan on top of autism treatment hours
EXCEPT if funds came from Private Fundraising (as, Dane County Families Can’t Wait) or one-time use regular funds – counties do not have to add either of these funds to waiver
if deemed no longer eligible for Family Support, be sure to appeal (as long as still meet “level of care” requirement)

CIP1B

continues through adult; Children’s waiver – only thru 22
State will “HOLD” waiver slot till adult if go into Children’s waiver
DHFS agreed they would put this in writing!!!

SED Services

A card service… In-Home Psychotherapy Program
Requires a clinically-diagnosed mental illness (as, bipolar, etc.);autism only NOT count
Focus of treatment has to be on treatment of mental illness, per a clear PA

DHFS Survey on Independent Assessment

145 responses (Psychologists, pediatricians, neurologists, etc)
10 different tests were mentioned by at least 5 diagnosticians

Additional Autism Coalition discussion

“Moratorium” on New Kids right now

WHAT IS A “REASONABLE DELAY”?!!! (ie, time to make sure enough $ vs default on original agreement with Autism Coalition of 250 new slot guarantee in waiver)
Coalition determined that 2/26 is drop-dead time for letting us know # of 250 slots used since July 1 and # slots remaining
250 slots was THE DEAL

Suggestion for communication – Electronic Live Chat Room for providers & DHFS on same day/time monthly
Michelle Sturz – has not received answer to questions sent to DHFS; will bring to next Coalition meeting
The large group reviewed the “Joint Priorities of the Autism Coalition & FEAT for the Winter 2004 Legislative Session” document drafted by small group of Autism Coalition 1/7/04 meeting

Liz Hecht will send out the revision reflecting the large group discussion for additional AC input

Previous Updates

The WI Dept. of Health & Family Services (DHFS) is in the process of implementing significant changes related to the provision of intensive in-home autism services. The Medicaid home and community-based service waiver (Children’s Long Term Support - CLTS), which includes provisions for autism services, has been submitted to the federal Centers for Medicare & Medicaid Services (CMS).

At the Sept. 15th meeting of the Autism Coalition1, discussion included: 1) status of waiver, 2) continued Coalition support for waiver provisions, 3) concerns/observations about key stages of transition to the waiver; 4) post-intensive services, and 5) next steps. DHFS staff shared this information about the waiver:

DHFS will post waiver updates on its website: www.dhfs.state.wi.us (Search – autism)
Timeline:

6/19/03 – DHFS submitted CLTS waiver to CMS. (90-day timeline for review= 9/19).
9/12/03 – CMS new list of waiver questions sent to DHFS, which “stops clock” and essentially starts another 90 day timeline for CMS waiver approval (i.e., 12/12/03).
10/1/03 – counties’ deadline to inform DHFS if will implement waiver (if not, DHFS will administer the waiver through a contract with a provider in the area to coordinate waiver);

Implementation is expected to be done in phases, with smaller counties being able to implement the waiver within the first month after CMS approval, larger counties may implement intensive children in a first phase and post-intensive in second phase.
Services will not change to waiver without the family’s knowledge; someone will meet with family first to develop a service plan.
$96/day average cost of intensive waiver slot; $28/day average cost of post-intensive slot.

The Coalition reached informal agreement with DHFS staff present at the meeting and sent a letter of request to DHFS 10/2/03 regarding:

DHFS agreed to send email updates, twice monthly, to Autism Coalition contact (Liz Hecht, who will forward to full Coalition), until initial implementation of waiver is complete.
DHFS agreed to answer questions (within 10 days) submitted by families and providers to Autism Coalition contact (Michelle Sturz, msturz@charter.net ) to ensure availability of timely, accurate information. For most current Q&A: http://www.asw4autism.org/Inhome/ihapqa.htm
DHFS agreed to send a formal communication to counties ASAP clarifying the description of post-intensive services, in particular making it clear that in-home behavioral treatment is one of the options for families to access as a post-intensive service through the waiver.
DHFS agreed to send a formal communication to counties clarifying the state’s policy regarding “holding families harmless”, i.e., if parents are receiving services through their county prior to going to the waiver, under what circumstances are the counties allowed (or not allowed) to discontinue those services.
Coalition requesting DHFS to dialogue with existing in-home autism providers to ascertain: a) which of these providers is willing to provide post-intensive services, b) what technical assistance these providers need from the state, and c) if there is not an adequate network for the provision of post-intensive services, that DHFS develop a strategy to expand the network of providers.
DHFS agreed to inform the Coalition of the “pattern” of decisions made related to the 40 appeals that have been filed with the state since 7/1/03 regarding denials of service to children with autism under the Medicaid card.
DHFS agreed to clarify (soon) what criteria will be used to make decisions regarding exceptions to the 3-year limit for intensive services. The Coalition requested that DHFS first develop DRAFT criteria and a DRAFT of the process and provide an opportunity for parents, advocates, and providers to comment on the DRAFTS before they are finalized.
Coalition requesting DHFS to conduct a fiscal analysis to estimate the cost to the state of allowing children who began receiving services after their 8th birthday, but who have not yet received 3 years of service, to complete 3 years of intensive service. This information would help the Coalition determine whether to raise this issue in the January legislative session.

DFHS staff provided information about the waiver at the Sept. 26th ASW Fall Conference:

The longer the waiver approval takes, more quickly the $26.5 Million state budget funds will be used up, reducing amount available for rest of biennium budget years.
New slots (children not currently served) will have 1 month wait period; priority in order received.
Family cost-share not expected to start until early 2004.
New DHFS form, “Individual Service Plan – MA Waivers,” will be used for each child to outline expected outcomes and related supports/present level of functioning/measure for each outcome.
Intensive autism waiver services proposed to CMS (Appendix B-1, SPC 512), included:

Independent evaluation required before starting services (Note: children already receiving services will automatically move to waiver without this evaluation.)
Services must start before child is 8 and be limited to 3 years (Note: DHFS criteria for variances not available yet; though DHFS noted that few will be granted, as each variance granted would use one of the 250 slots for new children eligible for intensive therapy)
Intensive levels of service are defined 25-35 hours of face-to-face contacts/week per Individual Service Plan for child.
Post-intensive phase: after 3 years of intensive services, or if not making progress towards outcomes in Individual Service Plan, child will transition to other waiver services
When receiving intensive autism services phase, no access to other home & community-based waiver services.
Only services not reimbursable under State Medicaid Plan reimbursable with waiver funds.
Cost of travel time may be included in rate paid to providers
Standards for personnel described (Note: one change is that Line Staff requirements changed – 18 years, high school graduate, 30 hours of direct supervised experience in use of intensive autism therapy or 160 hours work with child with ASD in any setting.)

Other services available under the waiver, post-intensive phase, which may be accessed to age 18:

Adaptive aids; communication aids; consumer education & training (as, conferences), consumer & family-directed supports; daily living skills training; day services; home modifications; personal emergency response system; respite care; specialized medical & therapeutic supplies; specialized transportation; support & service coordination; supported employment; supportive home care.

Counseling and therapeutic resources: area which DHFS says can be used for continued intensive therapy, but at a greatly reduced number of hours (i.e., about 7 hours/day).

A provider panel at the ASW Conference discussed their various existing and proposed services under the waiver, including: community-based programs, recreation programs for social skills building, supported home care, in-home SED psychotherapy services, consultation, and ABA training for school staff.

The Legislature also allocated $1.3 Million for a few counties to enroll 90 children ($48.33/slot/day) in 2003 in the new waiver (i.e., not including children eligible for funding by the $26.5 Million being moved from the Medicaid “card” services for in-home therapy into the waiver).

Families for Early Autism Treatment (FEAT), families concerned about the dramatic reduction in services for children receiving autism services, especially post-intensive, is organizing and may be reached at: FEATWI@hotmail.com, 608-325-2518, or FEAT, P.O. Box 45825, Madison, 53744-5825.

The Autism Coalition is also concerned that post-intensive service level is inadequate and will result in expensive out-of-home placements. Other areas of inadequacy include: children starting after 8 and children cut before receiving a full 3 years of intensive service. The Coalition will address the need to seek increased funding through a budget repair bill. For waiver updates, Autism Coalition and ASW Legislative Committee efforts, visit the ASW website: www.asw4autism.org and also join the ASW-Autism e-group: www.asw4autism.org/budget%20surprise.htm.

1 A stakeholder coalition of over 50 organizations/agencies/individuals representing thousands of families, including Autism Society of WI, parents of children with ASD, Survival Coalition of Disability Organizations, WI Coalition for Advocacy, WI Council on Developmental Disabilities, school-related organizations, pediatricians, in-home therapy providers, and disability advocates.

Home : In-Home Therapy : Update: Intensive In-Home Autism Services