Exploring Options for Addressing the IDD Wait List in Arkansas

1. Arkansas Health Care Reform Task Force – ID/DD Wait List Exploring Options for Addressing the Wait List for the DDS Alternative Community Services (ACS) Waiver Program for the Intellectually Disabled and Developmentally Delayed March 2016

2. Executive Summary • TSG reports what a new waiver benefit would look like for the 2,640 people on the ID/DD wait list • Top-5 benefits except Supportive Living

3. Agenda • Review historical spending for Waiver program • Report results of a survey of households on the wait list • Model the effect of alternative capped a range of alternative waiver programs • Recommend path forward

4. Waiver Background • Improve the quality of services through Home and Community Based Waiver Services provided under a 1915 waiver for a limited number of individuals as an alternative to ICF/ID placement • Serving targeted populations: mental illness, and intellectual, developmental or physical disabilities with an age of onset before age 22 • Participation capped at 3,9881, with turnover, served 4,127 different individuals in SFY2015 • Wait list of 2,640 1 - http://humanservices.arkansas.gov/ddds/waiverDocs/ACSWaiverGuidebook.pdf

5. Services • Supportive Living – enable beneficiaries to live in their own homes, with their family, or in an alternative residence • Respite Services – short-term benefits for beneficiaries unable to care for themselves due to absence of non-paid caregivers • Supportive Employment – enable beneficiaries who need intensive ongoing support to perform in a competitive work setting • Adaptive Equipment – equipment to increase, maintain or improve functional capabilities to perform daily life tasks • Vehicle Modifications – adaptations to an automobile or van to accommodate the special needs of the beneficiary • Environmental Modifications – modifications made to or at the beneficiary’s home

6. Services (cont.) • Specialized Medical Supplies – items necessary for life support not otherwise available under Medicaid • Supplemental Support Service – enable community living, in response to crisis, emergency or life threatening situations • Case Management Services – assistance in gaining access to needed services, in or out of the Waiver • Consultation Services – clinical and therapeutic services • Crisis Intervention Services – in the beneficiary’s home or other local community site by a mobile intervention team • Community Transition Services – set-up expenses for beneficiaries who are transitioning from an institution

7. SFY2015 Services by Claim Amount Claims data from SFY2015 federal Expenditures Report 96% of Waiver Spending is for Supportive Living 20% of beneficiaries spend less than $20,000 – 80% less than $70,000

8. Spending by Service Type Claims data from SFY2015

9. Supportive Living Averages $49,000 Claims data from SFY2015

10. Cost of Services Other Than Supportive Living Claims data from SFY2015

11. Services other than Supportive Living Rarely Total More than $6,000 A program capped at $6,000 would meet 96% of needs other than Living Support Claims data from SFY2015

12. A Program Capped at as Little as $6,000 would Cover Most Historic Claims -- Except Supportive Living Claims data from SFY2015

13. Agenda • Review current spending for Waiver program • Report results of a survey of households on the wait list • Model the effect of alternative capped a range of alternative waiver programs • Recommend path forward

14. Survey Method • Survey invitation sent by US mail to 2,640 individuals on the wait list • Asked to rank the top 5 most important benefits from the list • Respondents responded by using a web survey • Asked for comments at the end of the survey • Offered the opportunity to respond anonymously or provide detailed contact information • Respondents spent an average of 8 minutes responding (long for a web-based survey). This suggests they took it seriously

15. Responses Covered the State • 440 responses in 10 days—17% response rate • 81% provided addresses • All but one provided a comment • Responses represented the entire state Note: 81% of responses provided name and address, only these are graphed

16. How the Services were Ranked

17. Services by Rank

18. Summary Findings from Survey • Supportive Living is #1, but not as strongly favored as the 97% of current Waiver participants that claim for Supportive Living • Respite and Case Management are clear #2&3 for those on the wait list • Responses are widely dispersed—strongly supporting the notion of self-determination of services • Response rate, and number, size and tone of comments all suggest that the wait list is a very unhappy group, looking to the legislature for quick relief • Respondents would rather have some benefits even if it is less that the whole Waiver program • Respondents seek more self-direction • The selection process should be faster, clearer and more transparent

19. Agenda • Review current spending for Waiver program • Report results of a survey of households on the wait list • Model the effect of alternative capped a range of alternative waiver programs • Recommend path forward

20. What if… • TSG has modeled a waiver like those in Indiana, Tennessee and Kentucky. It would… • Provide a benefit capped at an amount much smaller that the average of claims for those already on the Waiver • Allow recipients substantial latitude to spend up to the cap on any of the services. Both models assume that for most beneficiaries, the capped amount would not be sufficient to fun a meaningful part of Supportive Living • This model considered simply for the purpose of understanding what might result from such a capped benefit

21. TSG Developed the Model Based On • Assumptions: • Services usage based on survey responses • Services cost based on historic Waiver claims • Assuming the program would allow beneficiaries to claim services up to the cap • Excluding Supportive Housing from the value assessment, as we know it averages $50,000, beyond other state caps • Seeking to find out: • What services would beneficiaries likely spend the capped amount on? • How far would the capped benefit go towards “buying” all of their 5 highest ranked services? • How much would the two scenarios cost in total, assuming 2,640 people came off the wait list into the new waiver program

22. Self-Directed Benefit Simulation 86% 72% 72% of top-5 needs (other than Supportive Living) met by a cap of $12,000 86% by a benefit capped at $15,000 The #4 & #5-ranked services are often the more expensive ones

23. Agenda • Review current spending for Waiver program • Report results of a survey of households on the wait list • Model the effect of alternative capped a range of alternative waiver programs: Next Task Force Update • Recommend path forward

24. Full Cost of Capped Waiver for 2,640 on the ID/DD Wait List