Chapter 257 of the Acts of 2008 Provider Information and Dialogue Session:

Chapter 257 of the Acts of 2008 Provider Information and Dialogue Session: Adult Placement & Adoption Services & Supports May 23, 2011 www.mass.gov/hhs/chapter257 eohhspospolicyoffice@state.ma.us

Agenda • Chapter 257 of the Acts of 2008 • Overview of Adult Placement & Adoption Supports & Services • Definition and Overview of Programs • Rate Considerations • Feedback from March 21, 2012 Session • Review of provider-developed integrated assessment and pricing model • Individual Client Need Assessment Tool • Staffing Levels • Stipend Levels • Break Out Groups • Timeline and Key Milestones

Chapter 257 of the Acts of 2008 Regulates Pricing for the POS System • Chapter 257 places authority for determination of Purchase of Service reimbursement rates with the Secretary Of Health and Human Services under MGL 118G. The Division of Health Care Finance and Policy provides staffing and support for the development of Chapter 257 pricing. • Chapter 257 requires that the following criteria be considered when setting and reviewing human service reimbursement rates: • Reasonable costs incurred by efficiently and economically operated providers • Reasonable costs to providers of any existing or new governmental mandate • Changes in costs associated with the delivery of services (e.g. inflation) • Substantial geographical differences in the costs of service delivery • Many current rates within the POS system may not reflect consideration of these factors. • Chapter 9 of the Acts of 2011 establishes new deadlines for implementing POS rate regulation as well as requires that related procurements not go forward until after the rate setting process is completed.

The Cost Analysis and Rate Setting Effort has Several Objectives and Challenges Pricing Analysis, Rate Development, Approval, and Hearing Process Objectives and Benefits • Development of uniform analysis for standard pricing of common services • Rate setting under Chapter 257 will enable: • Predictable, reimbursement models that reduce unexplainable variation in rates among comparable, economically operated providers • Incorporation of inflation adjusted prospective pricing methodologies • Standard and regulated approach to assessing the impact of new service requirements into reimbursement rates • Transition from “cost reimbursement” to “unit rate” Challenges • Ambitious implementation timeline • Data availability and integrity (complete/correct) • Unexplained historical variation in reimbursement rates resulting from long-term contracts and individual negotiations between purchasers and providers • Constrained financial resources for implementation, especially where pricing analysis warrants overall increases in reimbursement rates • Cross system collaboration and communication • Coordination of procurement with rate development activities Data Sources Identified or Developed Provider Consultation Cost Analysis & Rate Methods Development Provider Consultation Review/ Approval: Departments, Secretariat, and Admin & Finance Public Comment and Hearing Possible Revision / Promulgation

Updated timeline reflects critical milestones in meeting statutory requirements. • Department Service Design Finalized: All service components, staffing ratios, staff qualifications, other program inputs have been decided by the purchasing department. • Provider Input Sessions: For each rate setting project, EOHHS conducts an average of 3 provider input sessions prior to Executive Sign-Off and the Public Hearing process to allow for greater depth in understanding core program components, cost drivers, and procurement considerations. • Executive Sign-Off: Commissioner and C257 Executive Committee sign-off on draft rates and implementation plan. • EO485 Submitted to ANF: Draft rate regulation to ANF; Will better align the rate regulation proposal with budget planning. • Procurement Issuance: Where a procurement is warranted, the procurement will be issued after the rates have been adopted. • Rates Effective: Where possible, reimbursement under regulated rates will align with beginning of SFY to minimize mid-year contract amendments for both purchasing Departments and providers.

Agenda Chapter 257 of the Acts of 2008 Overview of Adult Placement & Adoption Supports & Services Definition and Overview of Programs Rate Considerations Feedback from March 21, 2012 Session Review of provider-developed integrated assessment and pricing model Individual Client Need Assessment Tool Staffing Levels Stipend Levels Break Out Groups Timeline and Key Milestones

Adult Placement & Adoption Services & Supports Service Class Definition: Programs that provide a continuum of services relating to foster care, shared living placements and adoption, including recruitment, placement, and supports to individuals, families, and caregivers to promote stability in the temporary or permanent family placement.

Rate Considerations • Currently, DDS & MCB Contract and reimbursement levels reflect individually negotiated rates with each provider • DDS & MCB are working with DHCFP and EOHHS to develop a standardized rates for reimbursement to assess the need of each client that receives Placement and Adoption Supports and Services. These rates will consider: • Staffing levels • Client intensity • Stipend levels • Maintaining access to services is an important goal in the rate development process • DDS Contract Data from Fiscal Year 2011 and EIM claims units used in analysis. The data represents a wide mix of program models and levels of participant need.

Feedback from March 21, 2012 Provider Consultation session Individual Client Need • Rate setting should be based on individual need. • Provider assessment model tool looks at intensity needs & costs out levels. As need increases, stipend increases. • Will nursing be considered as individuals are evaluated? • If need goes beyond what the rate covers, will there be an ‘upper’ rate? Program Staffing • How will Direct Care staff be included within the methodology? Staffing positions can vary across the spectrum. • Will training/vacation respite be included in the rate structure? • Rates should reflect the defined roles and qualifications for the case managers. Stipend Levels • Stipend levels are inconsistent and the data on the stipends is not a good informant of the actual costs of serving the clients : • Varying levels of need are not accounted for in the stipend structure • Build the stipend based on the assumed costs to provide these services

Provider-developed integrated assessment and pricing model: Individual Client Need Assessment Tool • Assess the level of need of the clients supported within shared living/home care services. • 4 point scale of need from least intrusive to most intrusive • Evaluates clients’ personal skill ability in a variety of daily living domains • Questions related to the following are given greater weight in the scale: • Medication Compliance • Incontinence • Sleep Difficulties • Medical and Mental Health • Behavioral Support Needs • Physical (motor) Health • Risk Status • Oversight requirements • Deafblind • An executive summary, used in concert with the assessment tool, allows for final client scores to reflect other issues that could impact placement viability in the home, to the stakeholder agency, for the family or specific to the client.

Provider-developed integrated assessment and pricing model: Staffing Structures • Each defined level is linked to a distinct program model and budget • As the level of service need increases: • Number of people in program model decreases; lower staff-to-client ratios • Clinical, nursing, direct care/respite, training placement specialists, and oversight supports increase • All programs reflect a full-time Program Director and two full-time Assistant Program Directors and a part time Placement Specialist

Provider-developed integrated assessment and pricing model: Budget Configuration and Stipend Levels • Note: Distributed Materials represent a provider-developed pricing model. These materials are not an EOHHS/HCFP/DDS/MCB work-product or reflect their recommendations; they are for discussion purposes only. • Review of provider-developed budget models • Staff Salaries • Caregiver stipends • What do your agency’s stipends include? Food, housing costs etc? • Other Program Costs • What are important ‘other’ program cost drivers? • Respite • How is respite addressed in your agency? • How are Charges for Care addressed?

Updated Implementation Timeline and Key Milestones for Adult Placement & Adoption Services & Supports July 1 • Department Service Design Finalized: All service components, staffing ratios, staff qualifications, other program inputs have been decided by the purchasing department. • Provider Sessions: For each rate setting project, EOHHS conducts an average of 3 provider input sessions prior to Executive Sign-Off and the Public Hearing Process to allow for greater depth in understanding core program components, cost drivers, and procurement considerations. • Executive Sign-Off: Commissioner and C257 Executive Committee sign-off on draft rates and implementation plan. • EO485 Submitted to ANF: Draft rate regulation to ANF; Will better align the rate regulation proposal with budget planning. • Public Hearing: DHCFP and purchasing departments consider testimony in advance of rate adoption. • Procurement Process: The procurement will be issued after the rates have been adopted. • Rates Effective: Where possible, reimbursement under regulated rates will align with beginning of SFY to minimize mid-year contract amendments for both purchasing Departments and providers.

Questions/Feedback Please Email Questions & Comments to: eohhspospolicyoffice@state.ma.us Please Visit the Chapter 257 Website: www.mass.gov/hhs/chapter257

Chapter 257 of the Acts of 2008 Provider Information and Dialogue Session: