STATE OF WISCONSIN
Department of Health and Family Services
DLTC Info Memo Series 2008 - 8
Division of Long Term Care
Date: August 28, 2008
Index Title: LTC Fiscal Update Memo # 9
To: Listserv
For: County Departments of Human Services Departments
County Departments of Social Services Directors
County 51 Directors County Fiscal Contacts
County COP and Waiver Coordinators
Children's Services Specialists
From: Sinikka Santala Administrator
Subject: LTC Fiscal Update Memo #9
The purpose of this memo is to clarify planning instructions for
counties transitioning to long-term care managed care.
BACKGROUND
As previously detailed in Managed Long-Term Care Expansion Planning
Informational Memo #5, counties are required to submit initial
transition plans to the Department of Health Services (DHS) three months
(90 days) prior to the anticipated first date of enrollment in managed
long-term care in that county. This plan must clearly indicate both the
total number of current waiver participants and the total number of
individuals on the county's waiting list. Counties are required to
process the enrollment of current waiver participants into Family Care
within six months of the program first being offered. Enrollment from
the waiting list is to be distributed over 24 months.
ENROLLMENT PLANNING
In order to formulate an accurate budget for Family Care expansion,
DHS was required to project the pace and nature of expansion. A key
assumption of this projection is that the careful regulation of the
speed of the enrollment of current waiver program participants and of
individuals on wait lists into managed care is essential in order to
stay within appropriated expenditure levels. Another assumption is that
savings generated by bringing the care of former waiver participants
under management using the principles of Family Care will generate part
of the savings needed to serve those on wait lists. Using these
projections, DHS determined that any county's waiver participants could
be enrolled over a six-month period, allowing Managed Care Organizations
(MCOs) time to ramp up to full capacity. DHS projected that those on
waiting lists could be enrolled over a 24-month period, which also
coincides with the period of time before entitlement is required in any
county where Family Care is implemented. Finally, DHS projected that
curtailing all new waiver approvals beginning 90 days prior to Family
Care implementation in any county, except in very select circumstances,
was required in order to finalize case counts and regulate the flow of
enrollment to Family Care.
The amount of the Department's request for funding for expansion was
made using these assumptions, with the expectation that these
assumptions would become the guidelines within which expansion would
occur. In implementing these guidelines, DHS allowed a degree of
flexibility that does not jeopardize the ability to stay within the
appropriation.
- Some long-term care districts have been granted permission to plan
for enrollment of all current waiver participants who choose Family
Care in a single month. This rapid transition from county operations
to district operations will challenge the district to bring care
"under management" quickly, but is not contrary to
appropriation guidelines.
- DHS has authorized Aging and Disability Resource Centers (ADRCs)
and MCOs to work together to replace individuals who disenroll from
an MCO with individuals from the waiting list, over and above the
number of individuals enrolled from the wait list under any county's
DHS approved transition plan (1/24th allocation). As a result,
enrollment of everyone waiting for services may take less than 24
months in some counties. Additionally, this replacement of enrollees
with those from the waiting list allows the ADRC to use its judgment
to prioritize enrollees whose needs are most urgent, regardless of
when a person with urgent needs comes to their attention prior to
Family Care entitlement in that county (24 months).
- DHS encourages continued relocations from nursing homes to the
community by not including relocated individuals among the DHS
approved monthly transition amount from the county's wait list
(1/24th of wait list).
Nevertheless, some counties have submitted new waiver care plans to
add large numbers of new participants in their waiver programs shortly
before the 90-day cut off date before Family Care enrollment begins.
DHS developed a budget request for Family Care expansion that relied
upon the key assumptions listed above being applied consistently during
expansion. These actions by some counties that deviate from the
expansion plan upon which the Family Care budget was developed, however
well-meaning, cannot be funded within the budget available to the
Department.
In order to more carefully regulate the pace of Family Care expansion
in individual counties, Community Integration Specialists (CIS) have
been instructed to carefully review the service components proposed by
care managers in new waiver approval requests. Because the number of new
care plans to add waiver participants to county programs has been quite
consistent, the Department has also instructed the CIS to alert the
Family Care management team to any unusual increases in the number of
plans being submitted as transition nears. If DHS finds that a county
has enrolled an unusual number of individuals in the months preceding
its planned transition to managed long-term care, DHS will adjust the
number of persons that it will allow the MCO to enroll from the wait
list until these "early enrollees" have been transitioned. The
effect of the county's action to serve these people earlier in the
waiver will be that DHS will consider them to have been made the highest
priority for enrollment by their county from the wait list, and those
remaining on the waiting list will be required to wait longer for
resources.
If a county has a specific concern that an individual who is waiting
for Family Care enrollment may be in crisis in the near future, the
long-term support unit should work with the ADRC to give priority to
that individual's enrollment. In some cases, this might result in an
earlier Family Care enrollment for this person. As a priority candidate
for enrollment among those on the wait list, the person might be offered
enrollment in months 1, 2, or 3 after implementation of Family Care in
his or her county, but as a newer waiver participant, the individual
might be among those offered enrollment in months 4, 5, or 6. We have
encouraged county, ADRC, and MCO collaboration in enrollment planning to
address individual circumstances.
The action that DHS plans to take to address the early enrollment
concern may best be described by an example. If County A is found to
have enrolled 30 individuals more than would typically have been
enrolled in the months leading up to transition and County A's DHS
approved transition plan calls for enrollment of six new people from the
wait list per month, DHS will suspend any enrollments from the county's
wait list until the 6th month after implementation of Family Care in
that county.
Removing significant numbers of individuals from a waiver waiting
list just prior to Family Care implementation in any county also has the
unexpected result of reducing the monthly number DHS allows to be
enrolled from the wait list each of the 24 months prior to entitlement.
In the example above, County A's approved monthly enrollment from the
wait list is six individuals; it had 144 individuals on its wait list
just before Family Care was implemented. If the 30 individuals who
enrolled earlier had still been on the wait list when DHS approved the
county's Family Care transition plan, the total wait list would have
been 174, yielding at least seven enrollments per month for 24 months.
All 30 people could have been enrolled within five months, along with
several others. Those others are disadvantaged by the county's decision
to enroll the 30 individuals earlier.
Finally, if all of the earlier enrollments to the waiver programs are
from a single target group, this action disadvantages those in other
target groups who are also waiting. Since DHS must stay within its
budget appropriation, disallowing enrollments from the waiting list for
the number of months it will take for the earlier waiver enrollees to
transition to Family Care, no enrollees from other target groups will
gain access to Family Care during that time.
If you have questions regarding these policies or the fiscal impact
of funding moves in light of your county's transition to long-term care
managed care, please contact a member of the Fiscal Management and
Business Services Section:
Rebecca Hotynski, Fiscal Unit Supervisor - (608) 264-9870 or Rebecca.Hotynski@DHS
.wisconsin.gov
Sue Liegel for COP and COP-W - (608) 266-9755 or Susan.Liegel@DHS
.wisconsin.gov
Lisa Kelly for CIP II - (608) 267-3659 or Lisa.Kelly@DHS
.wisconsin.gov
Karla Meyer for CIP I or BIW - (608) 266-0071 or Karla.Meyer@DHS
.wisconsin.gov
Bill Lorenz for CLTS - (608) 261-6751 or WilliamA.Lorenz@DHS
.wisconsin.gov
