Information For Families, Providers and County Staff
About Wisconsin's ICF/ID Restructuring
Initiative
The Initiative
Background
Implementation Steps
Relocation Report FY 2011
(PDF, 2.29 MB)
As required by section 51.06 (8) Wisconsin Act 386
Relocation Report FY 2010
(PDF, 1 MB)
As required by section 51.06 (8) Wisconsin Act 386
Relocation Report FY 2009 (PDF, 1.5 MB)
As required by section 51.06 (8) Wisconsin Act 386
Relocation Report FY 2008 (PDF, 1.4 MB)
As required by section 51.06 (8) Wisconsin Act 386
Relocation Report FY
2007
(PDF, 940 KB)
As required by section 51.06 (8) Wisconsin Act 386
Relocation Report FY 2006 (PDF,
265 KB)
In
response to section 51.06 (8) Wisconsin Act 386
Frequently Asked Questions
(updated April, 2006)
This website was developed taking key questions raised at regional
meetings into account. Additional questions and answers that further
define and clarify the initiative will be added as required.
Helpful Resources
THE INITIATIVE
The ICF/ID Restructuring Initiative provides two fundamental changes:
(1) New admission restrictions and corresponding
changes in periodic review processes, and (2) Realignment
of existing funding mechanisms and responsibilities, so that funding
that currently supports a person in an ICF/ID can follow that person into
the community. This "money follows the person" principle applies
to individuals who have a developmental disability level of care and who
resided in an Intermediate Care Facility for the Mentally Retarded (ICF/ID)
or nursing home in December of 2004.
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BACKGROUND
In Wisconsin, counties have the primary responsibility for the
well-being, treatment and care of individuals with developmental
disabilities.
For over twenty years the Wisconsin Department of Health
Services (DHS) has assisted counties in relocating individuals with a
developmental disability from institutions into the community.
The Department has a strategic goal of fostering the opportunity for
people with developmental disabilities to receive long term care in the
place of their choosing. Within this strategic goal, the Department has
adopted the short-term objective to assist county-operated and private
ICFs/ID to
downsize or close.
In 1998 there were over 2,200 ICF/ID beds in Wisconsin. As of June 1,
2004 there were under 1,500 beds in 33 facilities (not including the three
State Centers for the Developmentally Disabled).
In 1998 approximately 500 people with developmental disabilities
resided in general nursing facilities. In 2004 there were about 175
individuals with a developmental disability level of care remaining in
nursing facilities.
Since the Initiative started in 2005, over 744 individuals have been
relocated from facilities to the community. There are approximately 296 persons remaining in ICFs-ID and nursing facilities at a DD
level of care.
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New Admission Restrictions:
- Prior law required that protective placements (Chapter 50) be in the least restrictive
settings.
- New statutory language (s.
46.279) prohibits long term institutional placement for a
person with a developmental disability unless the institution
is the most integrated setting.
The most integrated setting is a setting that enables an individual to
interact with persons without developmental disabilities to the
fullest extent possible.
This determination must take
into account a community placement plan developed for the person by
the person's county of origin. This is a new requirement for counties.
Exception: emergency placements and temporary placements.
- Admission to nursing homes is also prohibited in the case of persons
with developmental disabilities needing needing active treatment
unless pre-admission screen determines care cannot be fully
met in an ICF/ID or community placement.
Exception: emergency placements and temporary placements as
defined by s. 55.06 (11) (c) or (12).
- Starting on January 1, 2005, ICFs/ID must notify the county of
residence of application for admission within 5 days.
- Counties have 120 days to develop community placement plans (or
within 90 days after extension of a 30-day temporary placement).
- These new restrictions also apply to annual reviews of protective
placements (Watt's Reviews), s.55.06(10)(a)(2)
for those reviews that are due on May 1, 2005 and after.
Watts
reviews occurring before May 1, 2005 will be subject to the new
requirements on their anniversary date starting in 2006.
- Medicaid coverage for the individual is lost if these procedures are not followed
(Chapter 49 is modified).
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Realignment of Existing Funding:
No change for the facilities:
- Facilities will continue to bill exactly as they have in the past.
- Facilities will be paid exactly as they have in the past.
Change for the Counties:
- Prior to the initiative, persons placed in facilities were paid for
out of a state appropriation that could not be used to support those
same individuals in the community. Counties will now be able to access
this funding stream when they move an individual from a facility to
the community.
In addition, this funding stream, which has been
declining each year, will increase going forward at the average
nursing home rate increase.
- Counties have a new responsibility to develop community care plans.
The county allocation will help them implement these plans.
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IMPLEMENTATION STEPS
Regional Informational Meetings:
- The Bureau of Long-Term Support [formerly the Bureau of
Developmental Disabilities Services], in the Department
of Health Services, Division of Long Term Care, conducted five
regional informational meetings during the months of April and May of
2004.
- The regional meetings provided the opportunity for ICF/ID providers
and county representatives to discuss the initiative.
- This website was developed, taking the questions posed at the
listening sessions into account.
Determining County of Residency:
- Facilities were asked to identify individuals at a developmental
disability level of care, and to notify the county they believed to be
the county of residency of the individual.
- Counties accepted or disputed residency, and those disputed cases
were resolved through existing residency determination processes.
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FREQUENTLY ASKED QUESTIONS
Download and print (PDF 42
KB)
- What is the context for the ICF Restructuring Initiative?
In Wisconsin, counties have the primary responsibility for the
well-being, treatment and care of individuals with developmental
disabilities. For over twenty years the Wisconsin Department of Health Services (DHS) has assisted counties in relocating thousands
of individuals with a developmental disability (DD) from institutions
into the community. Notwithstanding this history, a significant number
of Wisconsin residents with developmental disabilities still remain in
institutions and other large/congregate settings. Notice was taken of
the fact that the amount of money spent on persons in Intermediate Care
Facilities for the Mentally Retarded (ICFs) and nursing homes, at a DD
level of care, has been declining each year, due to a variety of
factors, (e.g. deaths, change of resident status to "no active
treatment" and relocations). As a result of the declining
expenditures, less funding was budgeted for the DD population in
facilities. It was determined that if the amount of state funding spent
on these individuals in facilities could be frozen and not diminished,
and could be used for relocations to the community as well as facility
care, the pace of relocations could increase.
- How did the change in state law impact the rights and options for
people with developmental disabilities living in institutions?
The court must take into account a county prepared plan for home or
community based care and the court "shall order that the person be
transferred to the non-institutional community setting in accordance
with the plan unless the court finds that placement in the intermediate
facility or nursing home is the most integrated setting…"s.
55.06(10).
- What are the new admission restrictions?
- "No person may place an individual with a developmental
disability in an intermediate facility and no intermediate facility
may admit such an individual unless, before the placement or
admission and after considering a plan developed".. by the
county (for home or community based care) a court finds that
placement in the intermediate facility is the most integrated
setting appropriate to the needs of the individual…" s.
46.279 ; and
- No individual requiring active treatment may be placed in a
nursing facility, and no nursing facility may admit the individual
unless it is determined (via PASARR) that the individual's need for
care cannot be fully met in an intermediate facility or in the
community. s. 46.279 (3).
- Are there any exceptions to
these admissions restrictions?
There are two exceptions:
- A person may be admitted without court order in an emergency and
subsequent temporary placement within the meaning of s. 55.06 (11)
(a) and (c); and
- A person may be admitted without court order to provide respite
for their guardian if they are living with their guardian. These
temporary placements are limited to 30 days, with an extension for
an additional 30 days, only upon court order.
- What does it mean to be in
the most integrated setting?
The most integrated setting is defined as "a setting that
enables an individual to interact with persons without developmental
disabilities to the fullest extent possible." It includes more than
just where a person lives; it involves who they live, work and recreate
with as well as utilizing the same aspects of (community) health care
that any person may require s. 46.279
- What has changed for
transfers between facilities?
The facility must provide notice to the court and the county no later
than 48 hours after transfer. The court must determine whether the
receiving facility is the most integrated setting.
- What funding changes are
associated with the initiative?
Funding that previously could only be spent on persons in facilities
is now available to relocate the remainder of people (with a DD level of
care designation) residing in ICFs/NHs to the community, through the CIP
1B waiver program.
- What is the responsibility of
counties in paying the state share of facility placements?
Legislation enacted in the 2003-2005 budget bill (2003 Wisconsin Act
33) requires counties to be responsible for the state portion of the
Medical Assistance payment made to ICFs and nursing homes for persons at
a developmental disability level of care (DD LOC). Since the beginning
of the Initiative, the DHS has been paying the state share of the
Medicaid payment to facilities on the counties behalf, to keep this
process as simple as possible and to minimize extra tracking burdens on
counties. The Department will continue to monitor facility utilization.
If it appears that counties are inappropriately admitting persons to
facilities the statutory responsibility for payment may be invoked.
- Who can be relocated from
facilities with money from this initiative?
The Initiative provides funding to relocate persons who were long
term residents in ICF and nursing homes at a DD level of care (DD LOC)
in December of 2004. This is a distinct (closed) set of individuals; no
one else qualifies for participating in this initiative, including
residents of the State Centers.
- How does the budget for this
initiative work?
The 05-07 biennial State Budget allocated approximately $94 million
AF (all funds) in FY 06 and $99 million AF in FY 07 to the ICF
Restructuring Initiative. The allocated funding must cover costs for the
1,412 individuals that are part of the initiative including all of the
following:
- All institutional costs (specifically all ICF or nursing home
costs billed through Medicaid);
- All home and community based waiver costs for any individual that
relocates to the community;
- The Medicaid card cost differential (which is the difference
between the costs of an individual's card services while they were
in the institution versus the cost of their card services in the
community);
- Phase-down agreements with facilities which are negotiated between
the Department and a facility (which in a safe and effective manner
allows facilities to close or downsize within a reasonable
timeframe);
- Loss of bed tax revenue due to community relocations and deaths;
and
- Funding in facilities for individuals who receive a No Active
Treatment determination.
- Will the ICF Restructuring
Initiative receive any of the funding from the nursing home rate
increase that was recently approved by the Legislature?
The nursing home rate increase that was recently approved by the
Legislature is for FY 06 and FY 07. In FY 06 the rate increase is
approximately $3,000,000 AF. This amount is for a one-time supplemental
nursing home rate increase. This funding will be distributed to NH,
ICFs-ID and managed care entities based on patient days. This amounts to
an increase of approximately $177,000 AF for ICFs-ID funding and should
be distributed before June 30, 2006. In FY 07 the rate increase is
approximately $23,000,000 AF. This amount will be used to provide a 2.8%
rate increase to fee for service nursing facilities, fee for service
ICFs-ID and managed care entities. This means approximately $1,200,000
AF will be provided for rate increases to ICFs-ID.
- How do you determine how much
money a person gets to relocate from a facility?
The county develops a plan that is approved by one of the
Department's Community Integration Specialists. The plan is forwarded to
central office and once approved there, the plan rate becomes the
"approved rate" for that individual.
- Do counties get to keep the
difference between an approved plan rate and actual expenditures?
No. Counties will be reimbursed for the costs of people relocated.
- If a county incurs costs for a
relocated individual that are greater than the approved plan rate, can
the county be made whole?
It is the Department's intent to fully fund people relocated under
this initiative. Procedures are being developed to review and adjust
individual plans of care on a periodic basis.
- Do counties ever have any
economic risk or financial liability for the cost of persons relocated
under this initiative?
The intent of the Department is to fully fund costs of care plans for
people relocated. We project that sufficient funding is available to do
this in the 2005-07 biennium. Our ability to maintain this into the
future depends on the cost of community care plans and the budget that
is provided for the initiative.
- How many individuals were
relocated in CY 2005? What were the average CIP 1B waiver costs of
these individuals?
- In CY 2005, 287 individuals relocated to the community as part of
this Initiative. The average daily care plan amount that was
submitted for these individuals was $213 AF per day.
- However, based on current HSRS data, the actual average daily paid
waiver cost for CY 05 was $186 AF per day.
- What is the county's response
and responsibility when they are informed by an ICF that an
application has been made to the ICF by one of the county's residents?
The county must develop a "plan for providing home or community
based care in a non institutional community setting." See s. 46.279
(4)(d).
- Who decides if the ICF is the
most integrated or not: counties or the court system of the county?
The court decides. See s. 46.279 (2).
- What is the court process for
determining the most integrated setting and what is the county's
responsibility if the county feels the ICF is the most integrated.
The court must take into account information presented by all
affected parties. The only specific piece of information identified in
state statutes is that a plan for home or community based care must be
developed by the county. The county must develop this community plan of
care even if they believe that the ICF is the most integrated setting.
- Are most integrated setting
orders needed for regular admissions to ICFs?
Yes. The requirement for court determination of most integrated
setting for these admissions became effective on January 1, 2005.
- Are DDES-822 forms still needed
for all ICF and nursing home admissions of persons with developmental
disabilities?
Yes. The form is a multipurpose tool used by counties to acknowledge
to facilities and to the Department that the county is aware of and
agrees to certain types of facility admissions for persons with a mental
illness and/or persons with a developmental disability. The form will
likely need to be updated by the Department to reflect nuances created
by the Restructuring Initiative.
- Are protective placement and
most integrated setting orders needed for short-term care (Medicaid
paid) admissions to ICFs from hospitals or nursing homes for temporary
medical/rehab care?
There is no exemption in the law for these admissions. The Department
is looking at drafting legislation that would permit certain short-term
admissions.
- Is Medicaid fee for service
funding available to pay for Respite Care services at an ICF?
No. Respite care in an ICF or in a nursing facility is not a Medicaid
State Plan covered service in Wisconsin. However, the CIP 1B waiver
program covers respite services in community settings and, in some
limited circumstances, in institutional settings with prior approval
from the Department. County case managers and state Community
Integration Specialists are familiar with the requirements for Respite
Care under the CIP 1B program.
- Funding follows people out of
ICFs to community placements, but none can go back to an ICF unless
there is a bed open (i.e. due to a death). What happens to people who
fail at their community placements? Frail elderly parents with adult
children who have significant health or behavioral concerns call about
this and complain that their counties have no answers.
This initiative, and many similar ones around the country, is an
effort to rebalance a system that has relied upon institutions to do
what was once the responsibility of families, neighborhoods and
communities. Changing the system will take some time. However, we
believe that improved funding of community services through this
initiative and other long term care reforms will increase the capacity
of communities and community providers to respond to the concerns
mentioned above, without needing to remove someone from their home. Many
aging parents (and younger parents too) have never had a child in an
institution, but they have had their child on a long waiting list for
services in the community. Our system needs to be responsive to those in
need whether or not they have been institutionalized. The Department is
now working with counties and other partners to expand managed long term
care statewide. This will eliminate waiting lists and will create a
broadened provider network to support frail elders, persons with
physical disabilities and persons with developmental disabilities.
- There's a lot of money
available now to move people to the community; but also a lot of
questions about how long the money will be there. Parents have
complained about being persuaded to accept education programs they
didn't like, with a promise that there would be funding; then the
funding was cut and they, along with their child, were left with no
option of going back to their previous service arrangement. What
assurances are there, that funding will be maintained for the
"high cost" community placements?
State budgeting processes do not guarantee funding beyond a biennium.
However, Wisconsin has a long-established history and commitment of
sustaining funding that provides critical supports to citizens with
disabilities. There is no reason to expect that funding will not
continue. In addition, as noted above, long term care reform across the
state will increase options for community services and will provide for
individuals who have significant (and sometimes costly) support needs.
- Families feel they are not
receiving services because of the Initiative. Some (especially those
who are single) parents of very medically involved children are
complaining that they are forbidden by their counties to admit their
child to an ICF and are expected to keep the child at home, but their
support services are inadequate and/or are being cut, and their
employment status is at risk because they continually have to stay
home because of lack of in-home support staff and/or the lack of
reliability that those who are scheduled will come to work.
While admission to an institution might resolve the work related
problem some parents face, it is unlikely to be a satisfying, long term
solution for children or their parents. Part of the problem identified
in the comments above relates to the funding imbalance in our current
system. This initiative, along with the expansion of managed long term
care, creates one of the first opportunities in decades to transfer and
combine institutional and other funding sources to expand community
services. This will improve the ability of counties and providers to
offer the kinds of services that families want and need without it being
necessary to default to institutional care for the reasons noted in the
comment.
- When families need to move to
or from WI (job changes, health crises) is there going to be a
legal/funding mechanism for their son/daughter to move with them or do
they have to be separated from the rest of the family?
Current residency laws and Medicaid rules apply. When a person moves
into a Wisconsin county, they are immediately considered the
responsibility of that county by there mere presence and intent to live
there. Relocations out of Wisconsin are dependent on the receiving
state's policies and procedures.
Last Revised:
April 22, 2013 |
