ARRM's Daily Dispatch

New Electronic Monitoring Requirement for Assisted Living Facilities

Many members received a bulletin from the Department of Human Services on Wednesday about the new requirements for electronic monitoring.

This language was passed during the 2019 Legislative Session as part of the broader Assistive Living Licensure Act.

Below, please find a list of settings that are defined in the bill as needing to comply with the new requirement.

• Licensed as a nursing home under chapter 144A
• Licensed as a boarding care home under sections 144.50 to 144.56
• Until August 31, 2021, a housing with services establishment registered under chapter 144D that is either subject to chapter 144G or has a disclosed special unit under section 325F.72
• On or after August 1^st, 2021 an assisted living facility

It is our reading, and we have confirmed with the Department of Human Services that this new requirement would not apply to ARRM Members providing ICF or 245D services.

ARRM will be reaching out to the Department of Human Services and the Office of Ombudsmen for Long Term Care to discuss the wording of the bulletin and request that they provide formal clarification on the services that must comply with this new regulation. Additionally, ARRM’s Technology Workgroup is going to begin drafting sample Electronic Monitoring Policies for members to reference and use when developing their own policies within their organization.

You can review the full Assisted Living Licensure Statute here.

Please contact me with any questions.

--Sara Grafstrom, Director of State and Federal Policy

Competitive Workforce Factor: Where Are We Now?

UPDATE: Published December 18, 2019

CMS Approves the Competitive Workforce Factor

In an announcement today, the Minnesota Department of Human Services informed all counties and providers it has received approval from the federal Centers for Medicare and Medicaid Services to apply the 4.7 percent Competitive Workforce Factor to Disability Waiver Rate System framework rates. Yay!

Providers and support teams can now move forward projecting the rates for service agreements renewing on or after Jan. 1, 2020 with full confidence in how the the frameworks will be calculated.

As a reminder, the overall impact of this implementation is projected to be an average increase to DWRS rates of 4 percent, equivalent to more than $150 million dollars over the next four years. It is paramount to forecast the impact for your own organization by reviewing each agreement, as the Competitive Workforce Factor only applies to direct staffing costs. Find information and resources in the ARRM Training Archive.

The department is moving quickly to update the Rate Management System, which should take place this evening.

---

Update on the Competitive Workforce Factor

Members will hopefully recall that implementation of the Competitive Workforce Factor is scheduled for January 1^st, 2020 on a rolling basis, dependent on final approval by the federal Centers for Medicaid and Medicare Services (CMS).

In order to get this federal approval, the state must submit a waiver amendment to CMS. ARRM has had conversations with department leads on the current status of the waiver amendment wanted to share the most recent information with you.

As of last Friday, August 16, it was shared with ARRM that the department anticipates the waiver amendment to be made available for public comment within the next couple weeks. Public comment must last for thirty days and following that, the department can send the waiver amendment to CMS; the department feels confident that this will happen in October.

The department also shared with ARRM that they have had conversations already with CMS about the Competitive Workforce Factor and will have follow up conversations once the amendment has been sent. Additionally, they shared that they are already in the process of updating their systems so they will be ready for implementation on January 1, 2020. They also wanted to note that if there is concern with any other items that are included in the waiver amendment, they would pull those items out and move the Competitive Workforce Factor separately, to ensure as quick an approval as possible.

It is important to remember that CMS does review public comment, both good and bad. Once the amendment is open for public comment, ARRM will be providing comments, and also providing information to our members on the steps to take to provide your own public comment.

We will continue to monitor the progress of the Competitive Workforce Factor and update you when we have any new information.

--Sara Grafstrom, Director of State and Federal Policy

Updates on Significant DHS Administrative Rollouts

Following the end of the 2019 legislative session, the Minnesota Department of Human Services (DHS) staff have been hard at work implementing some of the statutory changes to policies and procedures, as well as other administrative changes, which impact providers of residential home and community-based services (HCBS).

Provider Cost Reporting vs. Labor Market Reporting

The provider cost reporting requirements for DWRS were enacted prior to 2019 for the purpose of providing DHS with hard data to support research on the cost of providing services, and to make recommendations on component values and inflationary adjustments. This year, the final health and human services omnibus bill signed by the Governor included new requirements for labor market reporting to be used for assessments of workforce and service access. Providers may now be wondering about the similarities and differences between these data sets. Here’s a little chart that may help shed light on what needs to be done.

Cost Reporting	Labor Market Reporting
Collected annually on a 5-year cycle beginning in 2020 (20% sample of providers with rates calculated by DWRS drawn every year)	Collected annually: -DWRS providers beginning Fall 2019 -Other HCBS providers beginning in 2020
Gathers information about specific dollars associated with service provision based on current cost centers	Gathers information about direct care worker salaries, benefits and retention
Data to be submitted online via portal	Data submission method TBD
Measures the cost of providing services	Measures the health of the direct support workforce
§256B.4914, Subd. 10a, para. a	§256B.4914, Subd. 10a, para. g; §256B.4912, Subd. 1a

DHS Announces Implementation of the Account Validation Service (AVS) for Medical Assistance (MA)

Pursuant to §1940 of the federal Social Security Act and MN Statutes, §256.01, subd. 18f, DHS recently announced in a bulletin that it will implement its electronic asset verification program called the Account Validation Service (AVS) beginning September 1, 2019. This service will be used to help identify unreported accounts when determining Medical Assistance (MA) (Minnesota’s Medicaid program) eligibility for people whose MA basis of eligibility is MA-ABD (aged, blind, disabled). Applicants and enrollees must authorize the state to request information from financial institutions as a condition of Medicaid eligibility upon initial application, status change to MA-ABD, or annual renewal. This is of interest to HCBS providers because of the potential for delays in approval of the applications, especially if unreported assets are discovered, which can delay placement and/or reimbursement. For more information, refer to bulletin #19-21-02 found here.

Efficiency updates to assessment process, short-term institutional stays, DD screening document

DHS made several updates to streamline processes and procedures related to the DD screening document. While these changes apply most directly to lead agencies, residential providers should be aware of them.

Eligibility updates – a new page added to the Community-Based Services Manual provides information about eligibility updates, which can be used to extend the time in which lead agencies can determine program eligibility without another in-person assessment

DD assessments – the requirement for an in-person DD assessment has been removed for a change in the county of financial responsibility and guardianship status

Assessment applicability and timelines – policies about who participates in an assessment, and change in condition, have been updated

Short-term institutional stays – this policy has been updated to allow the DD waiver to remain open for people who have short-term (less than 30 days) nursing facility stays

DD screening document and code book – DHS has made changes to sections that include action types, legal representatives, exits and screening scenarios

The full announcement of these updates can be found here.

Reminder: Important HCBS Changes now in Effect

As members are aware, the 2019 Health and Human Service Omnibus bill contained many important changes to Home and Community-Based Service. Initial information that ARRM provided contained an effective date of August 1^st, however because these items were contained in an overall appropriations bill, the effective date is July 1^st. We have since corrected this information in past communications and have been communicating the new date to members.

The Licensing Department recently released further guidance on some of the changes that we wanted to share with you, specifically, what licensing will be looking for in verifying that members have come into compliance with the new requirements.

Annual Conversation on Technology:

During licensing review, licensors will confirm that providers discussed the use of technology during annual meetings and documented the discussions in the coordinated service and support plan addendum. Licensors will also review the documentation for a decision about the use of technology and an indication of whether more information is needed to make a decision.

Annual Training:

There is no longer a requirement for a minimum number of hours of annual training. Orientation and annual training requirements for the Positive Support Rule have not changed. The requirement to document staff training has not changed. Providers must document staff training according to Minnesota Statutes, section 245D.095, subdivision 5, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor.

Intensive Support Standards:

Service planning and delivery for in-home family support, in-home supported living services and semi-living services must now be provided following the standards of intensive support services.

For people currently receiving services, at the time of their annual service plan review, providers must follow the intensive support standards.

HCBS Billing and Service Documentation Requirements:

As a reminder, the following documentation standards must be met by providers:

• The date of the documentation
• The day, month and year the service was provided
• The start and stop times with a.m. and p.m. designations (for hourly or minute-based services)
• Service name or description
• The name, signature and title of the person providing the service. If the service is provided by more than one staff, the provider may designate one staff member responsible

Additionally, providers must have documentation that staff have reviewed and attested to the following statement on an annual basis: “It is a federal crime to provide materially false information on service billings for medical assistance or services provided under a federally approved waiver plan as authorized under Minnesota Statures, sections 256B.0913, 256B.0915, 256B.092, and 256B.49.”

ARRM has reached out to the department to get clarification on the expectations of providers to be in compliance with the requirement that all staff reviewed the above statement by the July 1^st date, we have not received a response and will update members as soon as we know more.

You can review the full Implementation Plan for 2019 Legislative Changes from the Licensing Division of the Department of Human Services below.

DHS Licensing changes 2019

Key HCBS Billing and Documentation Changes from the 2019 Legislative Session

Several amendments to documentation and billing requirements were passed during the 2019 Legislative Session for HCBS organizations to comply with. These include specifications around the detail needed for service and equipment documentation, from the language the documentation must be recorded in to the information required for service verification. These changes were specifically made in Minnesota Statute 256B.4912.

Download the reference sheet detailing all new HCBS Billing and Documentation changes, prepared exclusively for ARRM members.

Each of these requirements goes into effect on July 1, 2019. Failure to comply with these requirements may result in payments being recovered by the state. Please follow up with ARRM staff with any questions or clarifications.

New Policy to Support Expanded Use of Assistive Technology

Two important pieces of legislation passed during the 2019 Legislative Session which help expand the use of technology supports for people with disabilities based on the goals of individuals, their choices, the recommendations of the support team, and what will maximize independence.

Required Technology Conversations Expanded to Annual Meetings

A key pillar of the ARRM policy bill proposal was to broaden the requirement for support teams to discuss supportive technology options, from only being required at 45-Day Planning Meetings, to every annual support team meeting. The new language was added in the Intensive Support Services section of 245D.

Currently, a license holder must coordinate with a person’s support team or expanded support team in meeting at least once per year with:

• The person
• The person’s legal representative
• The case manager

The purpose of this meeting is to review the service plan and determine whether changes are needed.

Now, at the same or at a separate meeting, also at least once per year, they must also discuss how technology might be used to meet the person’s desired outcomes, and a summary of the discussion must be included in the service plan addendum. The summary is to include:

• A statement regarding any decision made related to the use of technology
• A description of any further research that must be completed before a decision regarding the use of technology can be made
• The coordinated service and support plan addendum is not required to include the use of technology for the provision of services.

The ARRM Technology Resource Center will be updating it's guide materials on required conversations.

Technology First Task Force Created

In another huge step forward, the Commissioner of Human Services is statutorily directed to appoint a Minnesota Technology First Advisory Task Force. The new task force will advise on strategies to increase the use of supportive technology in services and programs the Commissioner administers for persons with disabilities,  to enable them to live more independently in community settings, work in competitive integrated environments, participate in inclusive community activities, and increase quality of life. The advisory task force must include:

(1) one representative of the Department of Human Services;

(2) two representatives of the counties;

(3) one representative of the Associations of Residential Resources in Minnesota (ARRM);

(4) one representative from the Minnesota Organization for Habilitation and Rehabilitation (MOHR);

(5) one representative of the Disability Law Center;

(6) one representative of the Arc Minnesota;

(7) one representative from STAR Services;

(8) one representative from the Traumatic Brain Injury Advisory Committee;

(9) one representative from NAMI Minnesota;

(10) one representative from Advocating Change Together;

(11) two individuals with disabilities accessing supportive technology; and

(12) one parent advocate.

The task force will provide an annual written report with recommendations to the Commissioner by June 30 of each year of its existence, beginning June 30, 2020, and it sunsets on June 30, 2021.

 

Minnesota has great resources to learn more about the use of technology to support people with disabilities. Check out the Technology Resource Center, or join the ARRM Facebook group, the Technology Resource Center Community.

-- Ken Bence, Director of Research, Analysis and Policy

What Didn't Make It In the 2019 HHS Omnibus Bill, Wins and Setbacks

Equally important as the policy items that were included in the final Health and Human Service (HHS) Omnibus bill, are policy items that were not included. ARRM counts both wins and setbacks in this category this year.

WINS

ARRM put many resources into fighting against several damaging provisions proposed during the 2019 Legislative Session which would have both harmed providers’ abilities to operate, but more importantly restricted access to the supports and services sought by Minnesotans with disabilities.

Adult Foster Care Bed Closure Proposal

Early on in session, a bill was introduced by Human Services Reform and Finance Committee Chair, Sen. Jim Abeler (R-Anoka). This proposal would automatically decrease adult foster care bed capacity by one for every two beds left vacant for longer than six months.

ARRM had serious concerns about potential un-intended consequences to this proposal and testified in opposition to bill two separate times during the Human Services Reform and Finance Committee. Our testimony highlighted:

• The destabilization of adult foster care this proposal would cause
• The lack of consideration of regional variables or provider specific services
• The lack of cost savings this proposal would bring

Despite our opposition, this proposal did end up in the Senate HHS Omnibus bill.

As soon as the final HHS Conference Committee was announced we were able to activate our members in House Conferee’s districts. Thanks to member outreach, House members spoke against this proposal during Conference Committee and the language was NOT included in the HHS Omnibus Bill.

DD and CADI Waiver Caps

Similarly to the Adult Foster Care Bed Closure proposal, a proposal to cap the number of DD and CADI waivers at June 30, 2019 levels was also included in the Senate HHS Omnibus bill.

Many advocacy groups testified against this proposal during the Human Services Reform and Finance Committee, including ARRM. Thanks to the strong outpouring of opposition, this proposal was also NOT included in the HHS Omnibus Bill.

HCBS Licensing Fee Increase

As we have seen in past years, the Department of Human Services presented, and Governor Walz included in his initial budget, a proposal to increase licensing fees for Home and Community-Based Services providers. This proposal would have raised fees for providers based on revenue with increases ranging from 20 percent all the way up to 300 percent. One of the primary purposes of this new revenue is to support additional inspectors for the Office of the Inspector General.

While ARRM supports a strong and effective investigation process, the association raised strong concerns with generating new revenue from an unfunded mandate on providers already struggling to maintain wages and operations budgets. The association proposed alternative language which would have increased DWRS rates by an amount equal to the fee increases, keeping the proposal cost neutral. This was included in the Senate Health and Human Services Omnibus bill, while the House included language similar to the Governor’s proposal. Ultimately, neither were included in the final HHS Omnibus bill.

In the end, thanks to strong advocacy against these fees from our members, and strong advocacy on our behalf from key Senators, the increase to Home and Community-Based Services licensing fees was NOT included in the final HHS Omnibus bill.

SETBACK

ICF Variable Rate and Services During the Day Legislation

One of ARRM’s top legislative priorities this session was legislation that would allow all ICFs to request a variable rate and change the Services During the Day rate from 75 percent of the DT&H rate to 100 percent of the rate.

This legislation got off to an early start, with an early hearing in the Senate. Unfortunately the bill was not able to get a hearing in the House prior to the mandated committee deadlines.

Going into the end of the legislative session, the language was included in the Senate HHS Omnibus bill and there was momentum in the House, mainly driven by members of the minority party, to do something this session to address rates for ICF providers.

Unfortunately, due to a low final conference committee target, the ICF proposal was not included in the HHS Omnibus bill. This is a disappointment for ICF providers and in the coming months the ARRM ICF Taskforce will focus on re-capping what worked and didn’t work this legislative session and begin discussing ARRM’s priorities for the 2020 legislative session.

Thank you to Members

As indicated above, many of the provisions that we were successful in defending against were due to our member’s strong advocacy voice. Thank you to members who were able to contact their legislators in opposition to these harmful proposals!

--Sara Grafstrom, Director of State and Federal Policy

Possibly More Than You Ever Wanted To Know About Competitive Workforce Factor

The 2019 Legislative Session delivered many changes which impact Home and Community-Based Service (HCBS) rate setting, including key provisions targeting the workforce shortage issue. These changes will benefit HCBS providers’ financial stability and ability to invest in the Direct Support Professional (DSP) workforce both in the short- and long-term. It will also require organizations to adjust the way they forecast revenue and the data they need to collect and report to the Minnesota Department of Human Services (DHS).

Competitive Workforce Factor

As previously reported in “What You Need To Know About Competitive Workforce Factor” (05/28/2019), a new Competitive Workforce Factor (CWF) of 4.7 percent has been added to the Disability Waiver Rate Setting system (DWRS). This policy, a key priority of ARRM and the Best Life Alliance, was crafted and passed by legislators with the explicit intention of supporting wage increases for DSPs. It’s important to keep this in mind as we walk through how CWF will work.

Calculation

System wide, the CWF will add an estimated $64.2 million to HCBS waiver revenue over the next four years, or an average 4 percent increase to service rates.

But wait…we said the CWF is 4.7 percent; why the difference? Because CWF is a component factor of the DWRS formula which applies only to direct staffing costs and not a flat rate increase.

Therefore, it will generate a different increase for each individual’s rate based on the specific direct staffing costs associated with that service agreement and the other factors which compose the overall rate. We won’t know all the specifics until DHS releases their guidance and updated frameworks, but providers should begin to evaluate the impact of the new factor to their bottom line, To estimate how much new revenue will be generated by the CWF, providers should:

1. Look at the direct staffing part of the appropriate DWRS framework worksheet for each individual client
2. Apply a 4.7% adjustment to the amounts for on-site and remote awake staff, excluding supervision, RN and LPN
3. Add the 4.7% adjustment amount (the CWF) to the framework daily rate
4. Multiply the CWF by the employee related expenses amount (currently 23.6 percent) and add this amount to the framework daily rate for the total estimated daily rate

Encumbrance, or lack thereof

Beyond understanding the business impact, why is it important for providers to start calculating this?

Remember how we said earlier that the intent of this provision was to support DSP wage increases?

• While the new legislation DOES NOT REQUIRE an encumbrance of any new revenue for DSP wages and benefits…
• It DOES REQUIRE providers to identify the additional revenues generated from the CWF and prepare a written distribution plan for them, which must then be available and accessible to all direct care staff for at least a year

DHS is also directed to provide an analysis of the CWF to the legislature every two years, and the department will certainly be tracking the comparison of revenue increases from CWF to changes in wages during that time (as will ARRM). The legislature will have to take further action to authorize future adjustments to the CWF.

To ensure your organization stays ahead of questions from legislators, DHS, and your staff, it will be important to complete these internal analyses. ARRM is developing a webinar for additional guidance this issue which will be free for members and tentatively scheduled for July 19. Watch for more details.

Timing

The CWF will not change any rates until at least January 1, 2020. After that date, two milestones must have occurred for the CWF to begin delivering increases to a service rate:

1. The federal Centers for Medicaid and Medicare Services must have approved the new DWRS changes, including the CWF
2. Individual clients must be off banded rates. For clients that were previously banded, this will occur their first service renewal after January 1, 2020

Because the timing of these two factors will vary, again we cannot say exactly when providers will begin to see revenue increases but still encourage all providers to begin analyzing what the impact will be once CWF goes into full effect.

 

Download the accompanying fact sheet on CWF

***Have more questions about CWF? Ask them below -- others might have the same question.

2019 Health and Human Service Omnibus Bill Overview: What's In, What's Out

It's hundreds and hundreds of pages long, spends billions of dollars, and regulates thousands of state programs and private organizations. If you're thinking of the Health and Human Services Omnibus Budget Bill, you're right on!

ARRM has completed its review of this massive piece of legislation. This article walks through what's in, and what's out, and how it matches up with the association's priorities. Our team will be breaking down key provisions in an ongoing series of fact sheets and articles, but this provides your general overview. Items that are italicized will be featured in future blog posts in the coming two weeks with a more thorough background and analysis, items with an asterisk were included on ARRM’s 2019 Legislative Agenda.

If you have any questions about any of the items listed below, please feel free to reach out to Sara Grafstrom at sgrafstrom@arrm.org.

Included in the Health and Human Service Bill that we SUPPORT

• * Competitive Workforce Factor for DWRS at 4.7%: A Competitive Workforce Factor has been added to the DWRS framework at 4.7%. This adjustment will cost the state $34 million in 2020 and 2021 and $30 million in 2022 and 2023 and represents about a 4% increase in DWRS rates.
• * Change to the inflationary adjustment from every 5 years to every 2 years: Beginning in 2022, component factors will automatically be adjusted ever 2 years, using 30 month and 1 day old data.
• * Requirement of an annual conversation on technology: At annual planning meetings, providers must have a conversation about how technology may be used as a part of someone’s services.
• * Changes to the training requirements and qualifications for the Positive Support Professional, Positive Support Analyst and Positive Support Specialist position: Many changes were made to this service; one highlight is that the Positive Support Specialist and Positive Support Analyst now have 90 days to get their required training.
• * Removal of the hourly requirements for Annual Training: The hourly requirements that were in statute for the annual training requirement have been removed. Annual training and Orientation training is now competency based.
• Creation of a Technology First Advisory Council: A Technology First Advisory Council has been created with ARRM being granted a seat on the council. The goal of the council is to advise the commissioner on strategies to increase the use of supportive technology in services and programs.
• Direction to the commissioner for a Value-Based Models study: The commissioner, in consultation with stakeholders shall study value-based models and outcome-based payment strategies with a report due by October 1^st, 2020.

Not Included in the Health and Human Service Bill that we SUPPORT

• No caps to the DD and CADI waivers: A proposal that would have capped the DD and CADI waiver at June 30^th, 2019 levels was not adopted.
• No increase to HCBS Licensing Fees: A proposal that would have increased 245D provider licensing fees from 25-300% was not adopted.
• No new language relating to the closure of Adult Foster Care beds: A proposal that would have permanently closed one adult foster care bed for every two that are vacant for six months or more was not adopted.

Included in the Health and Human Service Bill that we OPPOSE

• New definition of shared respite: New language states that for shared respite, the rate shall be the total payment for one individual divided by the number receiving the service, not to exceed three.
• Removal of the ILS Specialist Service from the framework: The ILS Specialist Service has been removed from the framework and no longer available for providers to provide.

Not Included in the Health and Human Service Bill that we OPPOSE

• * No language allowing for the expansion of variable rates for ICFs and an increase in the reimbursement for Services During the Day: ARRM’s legislative proposal that would have allowed all ICFs to request a variable rate and would have changed the Services During the Day reimbursement rate from 75% of the DT&H rate to 100% of the DT&H rate was not included.
• * No extension of the licensing moratorium exception for adding a 5^th bed: During committee, the Senate amended our language around the 5 bed moratorium extension to 6 beds and removed the sunset language. There was opposition from the advocacy community around the 6 bed proposal and because of that, the entire proposal, including our language to extend the 5 bed sunset date was not adopted.

Included in the Health and Human Service Bill that we are NEUTRAL on and Impacts Members

• New definition provided for Residential program: A new definition of residential program has been added to 245A.02
• New HCBS Documentation and Billing standards: New documentation and billing requirements have been added to 256B.4912. ARRM worked closely with the department on this language over the last several years to ensure that this language is the least burdensome to providers.
• New language around change in ownership: The language provides direction and clarity for licensing and providers when a change in ownership occurs
• Electronic Visit Verification Language: Language allowing the department to move forward with EVV was adopted. The language states that any penalty that the department receives due to not coming into Federal compliance cannot be passed along to providers.
• New Labor Market Reporting Requirements: On an annual basis providers will be required to submit labor market data. Language is included in the bill directing the commissioner to streamline reporting as much as possible.
• Report and Proposal requirements for Waiver Re-imagine: A report and proposal to move forward to streamline the four waivers to two is required to the legislature by 2021.

Broader Disability Community Initiatives

• TEFRA Parental Fees Reduced by 15%
• MA Spend down for individuals with a disability eliminated
• Allowance of CDCS shared services
• PCA SEIU Labor Contracts ratified
• Bulk purchasing incontinence product program repealed
• MSOCS Operating adjustment