Additional Limits on Amount of Waiver Services. Indicate whether the waiver employs any of the following additional limits on the amount of waiver services (check each that applies).
When a limit is employed, specify: (a) the waiver services to which the limit applies; (b) the basis of the limit, including its basis in historical expenditure/utilization patterns and, as applicable, the processes and methodologies that are used to determine the amount of the limit to which a participant’s services are subject; (c) how the limit will be adjusted over the course of the waiver period; (d) provisions for adjusting or making exceptions to the limit based on participant health and welfare needs or other factors specified by the state; (e) the safeguards that are in effect when the amount of the limit is insufficient to meet a participant’s needs; and, (f) how participants are notified of the amount of the limit.
Limit(s) on Set(s) of Services. There is a limit on the maximum dollar amount of waiver services that is authorized for one or more sets of services offered under the waiver. Furnish the information specified above.
Prospective Individual Budget Amount. There is a limit on the maximum dollar amount of waiver services authorized for each specific participant. Furnish the information specified above.
The waiver assigns a prospective individual budget amount to each participant. The amount that is assigned to a participant is based in part on the individual’s previous service authorization amount and in part on the application of a statistically-derived algorithm that is designed to standardize funding among persons who have similar supports needs. The assignment of a prospective individual budget amount enhances participant choice in the selection of services and service providers and promotes funding portability. The implementation of prospective individual budget amounts also recognizes the importance of avoiding abrupt changes in the amount of funding available to current waiver participants during their transition to the new waiver.
The prospective individual budget amount is a limit on the overall amount of funds that may be authorized for COMP services. The prospective individual budget amount may not exceed the waiver’s individual cost limit as specified in Appendix B-2. When a participant elects to direct waiver services, the prospective individual budget functions as the participant-directed budget.
In order to link participant support needs and resource allocations, DHR selected the Supports Intensity Scale (SIS) assessment tool developed by the American Association on Mental Retardation (AAMR) to objectively measure individual supports needs. The SIS is a validated, reliable instrument for assessing the level of an individual’s supports needs in major domains of daily living as well as behavioral and medical needs. During the period November 1, 2005 – January 15, 2006, the SIS instrument was administered to a randomly selected group of 600 Mental Retardation Waiver Program and Support Services Waiver Program (CHSS) participants. The size of this sample was sufficiently large to ensure that it was descriptive of all waiver participants at acceptable statistical confidence levels. The results of these assessments were entered into a database along with additional information concerning the participant’s living arrangement (i.e., lives with family, lives independently, or resides in a community residential setting). A second database was created to capture information about the amount of services that had been authorized for the individuals in the sample.
Employing multiple regression analysis and other statistical techniques, SIS elements were isolated that are statistically significant in explaining differences in service expenditures, and a prospective individual budget amount assignment algorithm was developed. The resulting algorithm exhibits a
Appendix C: Participant Services
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State: Georgia Effective Date October 1, 2007
Appendix C-4: 2 high correlation between historical funding authorizations and measured supports needs.
Additionally, the algorithm satisfactorily explains differences in funding authorizations that stem from differences in objectively assessed supports needs. A description of the methodology used to develop this algorithm and the algorithm itself is available to CMS upon request. Also, the methodology for determining the prospective individual budget amount is available for public review and inspection upon request from the Office of Developmental Disabilities.
While the algorithm is highly predictive of necessary service authorization amounts, comparisons between current authorization amounts and the amounts generated by the algorithm revealed that relying solely on the algorithm to establish the prospective individual budget amount would result in significant changes in the funds available to some current waiver participants. To avoid
disruptions in current services and ensure continuity of services, the prospective individual budget amount during the first year of the waiver will be calculated as the weighted average of 80 percent of an individual’s historical authorization amount and 20 percent of the amount that a participant would receive through the application of the algorithm. This approach avoids abrupt changes in funding authorizations but paves the way for progressively tying authorizations to assessed supports needs. During the second year of the waiver, the prospective individual budget amount will be calculated as the weighted average of 60 percent of an individual’s historical authorization amount and 40 percent of the amount that a participant would receive through the application of the
algorithm. Finally, in the third year of the waiver, the prospective individual budget amount will be based 100 percent on the application of the algorithm.
Certain current participants will be assigned prospective individual budget amounts based on their historical authorization levels and needs. These individuals have historical authorization levels that fall significantly outside historical usual and customary service authorization levels. About 10 percent of all current waiver participants fall into this category. This treatment of “outliers” is standard practice in the application of funding algorithms of the type that DHR is implementing.
New enrollees to the waiver will be assigned the prospective individual budget amount that is generated by the algorithm. In the case of these participants, the SIS will be administered during the waiver enrollment process and the prospective individual budget amount will be determined by applying the algorithm to the SIS results. In the case of current waiver participants, the SIS will be administered in advance of the scheduled development of the ISP during the waiver transition period if the SIS has not been previously administered. If the participant believes that the SIS has not been accurately administered and is not an accurate reflection of his or her needs, the
participant may request a review of the SIS. In all cases, the support coordinator informs the participant of the amount of the prospective individual budget amount prior to ISP development. In addition, the support coordinator informs the participant of his or her rights to a Fair Hearing as specified in Appendix F-1.
The individual prospective budget amount will be adjusted in future years to reflect approved provider rate increases. In addition, the underlying funding algorithm will be periodically evaluated to confirm that the underlying elements upon which it is based continue to serve as reliable predictors of necessary resources based on assessed support needs. In the event that the algorithm is modified as a result of this evaluation or, based on experience with the algorithm, it is appropriate to modify the weighting of historical authorizations and the amounts generated by the algorithm, the State will submit a waiver amendment to CMS before implementing the modified method of calculating the individual prospective budget amount.
In the event of a major change in the participant’s condition or in the unpaid supports available to a participant (e.g., the incapacity of a family caregiver), the support coordinator may call an ISP review meeting. If the interdisciplinary team review determines a need for increased intensity of services, the Intake & Evaluation Manager or designee may approve a time-limited increase in intensity of services. If it is determined that a waiver participant has an extended need for an increased intensity of services, the individual may be re-assessed and moved to a higher COMP
Appendix C: Participant Services
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State: Georgia Effective Date October 1, 2007
Appendix C-4: 3 Program allocation.
Budget Limits by Level of Support. Based on an assessment process and/or other factors, participants are assigned to funding levels that are limits on the maximum dollar amount of waiver services. Furnish the information specified above.
Other Type of Limit. The State employs another type of limit. Describe the limit and furnish the information specified above.
Not applicable. The State does not impose a limit on the amount of waiver services except as provided in Appendix C-3.
Appendix D: Participant-Centered Planning and Service Delivery
HCBS Waiver Application Version 3.3 – October 2005
State: Georgia
Effective Date October 1, 2007 Appendix D-1: 1