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Comments on Shift of Supports Coordination from TSM to Waiver
By Speaking For Ourselves
November 5, 2007

We appreciate this opportunity to provide written comments on the ODP plan to move the provision of supports coordination into the Consolidated and PFDS Waivers. Given the short timeframe for the steps outlined in the letter from Deputy Secretary Casey, there is much to be accomplished in a very short time. Let us begin by supporting this shift in service location. By including supports coordination the Deputy acknowledged the benefit of freedom of choice for consumers. As with all services, a healthy competition among providers, if done properly, benefits the consumers in the end with a much higher quality service. While this move is the correct one it is not without problems and consequences. We are offering comments to assist ODP in their planning process as they move forward with this endeavor. We are hopeful through these comments that additional steps and processes will be added to ODP’s activities to bring about this change.

In developing a definition of supports coordination it is our hope that ODP will study the description of the function in the waiver contained in Medicaid Rules. We would encourage all allowable functions to be listed and included in the waiver definition for this service. This will provide clarity as well as information for participants to understand how and at what level their needs should be met by this service. The full functions of this role will assist in the rate setting process for this service as well. A clear definition will also help the team accurately determine the amount of service needed to include in the ISP as it is being developed. While changes in this level of service may be necessary if and when needs change, a clear definition could avoid any perception of ‘self-serving’ changes being created.

While ODP has indicated an understanding of the need to create a procedure to allow for freedom of choice of all qualified providers of supports coordination, it does not appear that any consideration has been given to the access of various supports coordination entities to the actual services their clients may need or the very approval of participant plans in a fair and equal way. Under the current system of services, the AE/County is charged with the provision or contracting of supports coordination. The AE/County is also charged with the responsibility to approve all ISP’s for consumers registered in their system. Although, on the face of it, this policy seems to violate CMS requirement for a single state Medicaid agency the procedure has been allowed to continue. With the advent of multiple supports coordination agencies/providers, AE/Counties who may also be providing the service or have ‘favored’ providers could approve plans more quickly or question items less for some providers of this service than others. While ODP, through its implementation of the service review process, has taken a more active role in the approval process it remains fairly clear that service reviews only occur when there is a disagreement between the County and the family/consumer about what services can or should be provided and the family/consumer has requested a fair hearing. Even when service reviews have occurred there have been cases of blatant disregard of the findings or directions given. For freedom of choice among supports coordinators to truly become a reality, ODP must fully assume the responsibility to assure they are the decision maker in a consistent, timely and unbiased manner for all ISP’s following waiver definitions and fulfilling all of the assurances previous given to CMS. Similarly, service providers must be sanctioned and their Medicaid contracts with the state terminated if it is found that they are denying equal access to their services to any supports coordination agency. This monitoring activity must be added to ODP’s oversight function.

While ODP has the right to determine qualifications for supports coordination providers we would encourage the consideration of the ability of culturally competent entities to provide this service especially in currently underserved or underrepresented populations. Training about and access to the HCSIS system must be assured for all SC providers while assuring a strict level of confidentiality. We would further strongly recommend that the function of supports coordination not be performed by agencies already providing other services within the MR system or the waivers. This is necessary to assure that consumers would not be funneled into other services within the agency providing supports coordination. This has long been an issue with residential providers who also provide day programs and more often than not consumers receive both services from the same provider. While this may be a desire at times, it frequently is just the way business is done. As this change begins to take shape, it is important to safeguard against the possibility of this practice carrying over to supports coordination and other services potentially available through the same providers. It would be important not to skirt this issue by establishment of subcorporations where one group provides services and another provides supports coordination.

Our final concern addresses the possible disconnect between populations in and out of the waivers. Two of the strongest links to folks having their needs known and addressed comes from the relationship between family/consumer and the supports coordinator and communication among supports coordinators within AE’s/Counties. We would encourage ODP to encourage independent (non-AE/County) supports coordination providers, which will form because of this change, to provide both TSM and waiver supports coordination. There also needs to be a transition plan whether consumers need to switch agencies when they go into waivers or not. A supports coordinator who knows a family/consumer’s needs and style plays a tremendously important role in helping to establish initial waiver services. With the different funding streams for waiver and non-waiver recipients we have a major concern about this transition process and the impact it can have starting with someone who may be extremely skilled but does not have the basic knowledge of the needs of the individual who may be transferred to them at a crucial time when they are developing their first ISP which will develop into waiver support. This need may have to be addressed through state funds since dual supports coordination billing cannot be done.

We hope these comments are helpful as ODP proceeds with the process of developing a plan to include supports coordination as a waiver service. We look forward to additional comment periods as the various draft policies and procedures are developed to bring about the inclusion of supports coordination within the waivers.