FSSA Releases Details of New Eligibility System- The Hybrid System

INDIANAPOLIS (December 14, 2009) - Indiana's Family and Social Services Administration has been known for bad customer service, subpar timeliness, and high error rates in the way it determines eligibility for Medicaid, Food Stamps (SNAP) and Temporary Assistance for Needy Family (TANF) programs. From 1990 to 2002, Indiana was fined eight times for more than $60 million by the federal government for its failure to make decisions on SNAP eligibility in a timely manner. Thirty-five percent of the Medicaid long-term care applications (FFY 2003) and 25 percent of the TANF applications (FFY 2006) approved by FSSA contained errors, and in FFY 2005, FSSA paid SNAP recipients $33.9 million more than they were entitled.

It was this crisis that led Governor Mitch Daniels in 2005 to begin the process of developing a system that would serve our clients better by offering more options to apply, a more accountable and efficient system, and a better customer service environment. What was then called the Eligibility Modernization project was intended to change the eligibility system from one where modern forms of access, such as the Internet and interactive voice response (IVR) systems, were not available. A system where 48 percent of FSSA clients found it difficult to reach their caseworker and 15 FSSA employees, along with 21 of their co-conspirators were convicted of welfare fraud.

As is common knowledge, the Eligibility Modernization project did not achieve many of the goals it set out to accomplish. Timeliness and accuracy remained low, and clients often complained of poor customer service. As a result, earlier this year, Governor Daniels and Secretary Anne W. Murphy cancelled the state's contract with International Business Machines (IBM), the company that had served as the prime contractor for the Eligibility Modernization project.

Since cancellation, FSSA has been working tirelessly to develop a new system to determine eligibility that would incorporate the lessons learned from both the old, pre-modernized system and the modernized system. FSSA began by soliciting input from providers, clients, advocates, employees, and the general public. FSSA established an email address (hybridinput@fssa.in.gov) and received hundreds of responses from individuals sharing their experiences and suggestions. FSSA also received responses by mail from individuals who did not have access to email. Additionally, FSSA created a small working group of providers and advocates from all around the state to provide input to the Division of Family Resources' (DFR) team as they were developing a hybrid.

The Hybrid System, detailed here, is a direct result of the lessons learned from pre- and post-modernization; input from clients, advocates, providers and the general public; and the work done by DFR staff. As the pilot region rolls out, FSSA will continue its dialogue with clients, advocates, providers and the public by keeping the email address activated, and establishing advisory groups in each region as they roll-out to continually receive updates on how the Hybrid System is working.

The Hybrid Plan:

After considering many different regions, the Vanderburgh Region will be the first to roll-out sometime in January (the exact date will be released in a subsequent announcement). The Vanderburgh region contains Daviess, Dubois, Gibson, Knox, Perry, Pike, Posey, Spencer, Vanderburgh, and Warrick counties.

The largest difference between the Hybrid System and the modernized system will be an increased focus on face-to-face contact.

County office staff will be increased. This staff will transfer from the Service Centers (more information on staffing changes in Vanderburgh County and changes to the Service Centers are detailed below).

Team Concept: FSSA caseworkers (SEMs) and contractor staff will be formed into teams that will work together on cases.

Clients will be served by a team in their county (as opposed to the modernized system, where your case could be handled by employees from all over the state).

Each team member will have the personal knowledge to assist their clients with their case.
Teams will allow newer workers to be paired with more experienced workers to learn from their example.

The two-tiered system will remain.

Under the two-tiered system, a different employee approves benefits than the employee who processes the case. This adds more accountability and allows mistakes to be corrected early.

Each team will contain both tiers.

The two-tiered system has helped to eliminate claims of employee fraud since it was instituted.

The increased options to clients seeking to apply for benefits, make changes to their case, or receive information or help with their case will remain.

Clients will still be able to fax/mail documents.

Clients who wish to call and talk to one of their team members will have their calls automatically transferred to their local office rather than a centralized call center (as was the case in the modernized system).

Clients will still be able to call the IVR to receive information on their case 24 hours a day, 7 days a week.

Clients will still be able to apply on the internet and complete their application by using the electronic signature.

To reflect a shift to a more personalized, locally based system, FSSA will now be communicating directly with area providers and advocates.

In the modernized system, FSSA contracted outreach and problem resolution to a vendor. In the Hybrid System, FSSA will communicate directly on a regional basis with providers and advocates. (For regional contact information, go to http://www.in.gov/fssa/dfr/4081.htm)

Providers and advocates will also receive periodic updates from FSSA on any changes or relevant information.

In the Hybrid Regions:

Regional Managers will have more control of day-to-day operations.

There will also be a Deputy Manager and additional supervisors to help in the management of the local offices.

In the Vanderburgh Region: 20 employees will be transferred from the Service Center to the county offices.

The remaining employees in the Service Center will staff the Change Center.

Change Centers are regional centers that will handle:

Medicaid-only redeterminations

All changes related to cases in their region

Processing of Food Stamp Interim Reports

Hoosier Healthwise ApplicationsBenefit Recovery

Document Center

There will be a centralized document center charged with attaching documents to the
appropriate cases.

County Offices:

County Offices will be equipped to help clients with all aspects of their cases.

Clients can apply, fax, or scan documents

Clients may talk to one of their team members

Specialized workgroups will exist for the Aged, Blind, and Disabled population

Contract Information:

Rather than contracting with one large entity, as was done in the modernized system, FSSA is in the process of establishing individual contracts with its vendors.

This will allow FSSA more direct control and management of their contracts and will improve responsiveness and accountability.

The contracts being established by FSSA have these major features:

The contract lengths are shorter than the contract with IBM.

The contracts are predicate upon the contractors meeting performance measures

Time-line for Hybrid System implementation:There is no time-line. FSSA will watch the pilot region carefully to make sure the Hybrid System is working before it begins planning the next region. Once the next region is determined, FSSA will announce the choice to the public.
Additional Information:

All other counties will remain under the system they currently have. Clients should operate as usual until FSSA announces any changes coming to their county.

As the Hybrid Plan was being developed, FSSA remained in constant contact with its federal partners.

During the implementation of the Hybrid Plan in the Vanderburgh Region, FSSA will continue working to improve timeliness, accuracy, and the client experience in the remaining regions.

-30-

Krieg DeVault Legislative Update

As you are aware, the Legislature has been hard at work, holding December hearings on a variety of issues that will be considered during the 2010 Legislative Session. Due to the short timeframe of the 2010 session, which requires the Legislature to adjourn by March 14, 2010, the Ways and Means Committee, the Tax and Fiscal Policy Committee and the Rules Committee all will hold hearings in December.

The Tax and Fiscal Policy Committee held two hearings on Senate Joint Resolution (SJR) 1, the constitutional amendment placing the tax caps already in state statute into the constitution. The committee did not have a quorum at the first hearing and so a second hearing was called to take official action. After hours of public testimony from trade associations and the general public, the committee approved the constitutional amendment 9-3, with Senator Connie Sipes (D-New Albany) joining the Republicans on the committee in voting yes. The other three Democrats voted no. Please find attached a copy of SJR 1 for your review.

The Ways and Means Committee has held two hearings and will hold a third hearing on Monday, December 14th to amend and vote on the legislation under consideration by the committee. In addition to hearing testimony on HJR 1, the constitutional amendment placing the tax caps already in state statute into the constitution, the House Ways and Means Committee has also held hearings on: House Bill 1003, Indiana Worker Preference on Public Works Projects, which requires contractors to employ a certain number of Indiana employees or risk losing contracts and House Bill 1004, Assessed Value of Homesteads and Farmland, which will place a cap on the increase in assessed valuation on a homestead or farmland in a given year. The committee will also hear House Bill 1003, Contracting of Public Assistance Eligibility on Monday, which prohibits the Family and Social Services Administration from contracting out certain intake functions for public assistance eligibility determination. Please find attached copies of these bills for your review. We will provide you an update on committee action next week, including any amendments added to legislation.

Also next week the House Rules Committee will hear testimony on House Bill 1001, Lobbyists, Campaign Contributions, authored by House Speaker Pat Bauer on Wednesday, December 16th. This legislation reduces the threshold for reportable expenses from $100 a day to $50 a day for legislative lobbyists. The legislation places a one-year "cooling off" period on legislators, barring them from lobbying the Legislature for 365 days after leaving office. The bill also prohibits campaign contributions for statewide elected offices during the Legislative Session and prohibits campaign contributions by individuals receiving contracts from the state. Please find this legislation attached for your review.

Legislation passing out of committee during December will be eligible for floor activity in the House and Senate on the first day of session. This means that the Legislature will be off to a very quick start in January when they reconvene for the 2010 session. As always, please do not hesitate to contact any member of our Government Affairs Team with any questions you may have.

Thank You,

Krieg DeVault Governmental Affairs Team

Phase II Final Rule Published

Today the Final Rule for Phase II was published in Indiana's Register.

Final Rule
LSA Document #09-215(F)
Amends 405 IAC 1-14.6-2, 405 IAC 1-14.6-4, 405 IAC 1-14.6-7, 405 IAC 1-14.6-9, 405 IAC 1-14.6-18, 405 IAC 1-14.6-21 and 405 IAC 1-14.6-23 through 405 IAC 1-14.6-25 to change the reimbursement methodology for nursing facilities and applicable definitions; add definitions of "allowed profit add-on payment" and "tentative profit add-on payment" and amend other definitions; change certain rate applicability dates, minimum occupancy rates,case mix index, the reimbursement to facilities that have more than eight ventilator-dependent residents, reimbursement for facilities that meet certain quality of care measures, special care unit reimbursement, and identify providers that are eligible for such special care unit reimbursement; change certain add-on applicability dates, allowable per day cost elements, the calculation of the administrative component, create allowed direct care component profit add-on in children's nursing facilities, define a new allowed direct and indirect care component profit add-on calculations, and a new allowed capital component profit add-on; change the end and effective dates of certain allowable compensation methodologies; change the end date of the collection of the quality assessment fee; and change the end date of the closure and conversion fund. Effective 30 days after filing with the Publisher.

Read more here: http://www.in.gov/legislative/iac/20091209-IR-405090215FRA.xml.pdf

Indiana Nursing Facility Medicaid Reimbursement Update “Phase II”

By Robert Thomas


The Select Joint Commission on Medicaid Oversight (SJCMO) approved the Family & Social Services Administration (FSSA) “Phase II” changes at its October 20, 2009, meeting. The rule which was published as LSA Document No. 09-215 in the May 2009 Indiana Register, received the support of all three long-term care trade associations at the September 30 meeting of the SJCMO. FSSA has indicated January 1, 2010, as the anticipated effective date of “Phase II.” Key elements of “Phase II” are:

Rebasing of the report card score add-on per diem based on each nursing facility’s latest published report card score as of the end of each state fiscal year (June 30). The revised add-on amounts are:

Report Card Score (RCS)Report Card Score Add-on Per Diem
0 - 82 $ 5.75
83 - 265 $5.75 – ((RCS – 82) x $0.03125)
266 & above $0

Note: The report card score add-on will not be subject to the Maximum Annual Increase (MAI) limitation.

Rebasing of the special care unit (Alzheimer’s unit) add-on per diem from $10.80 to $12.00 for each Medicaid resident day in the special care unit. The add-on per diem will be based on the resident assessment data (MDS) on file as of March 31 of each year and will be effective July 1 of each year.

Note: The special care unit add-on is subject to the MAI limitation.

For nursing facilities that qualify for the ventilator add-on payment, the add-on increases from $8.79 per day to $11.50 per day for all Medicaid resident days.

Increasing the minimum occupancy penalty from 85% to 90% for direct care and indirect care costs for facilities with greater than 50 beds.

Payment of a flat “price-based” amount for administrative costs versus the current cost-based methodology. The per diem will be 100% of the average allowable cost of the median patient day.

Reduction or elimination of efficiency rate incentives for the direct care, indirect care and capital components based on quality report card scores. Children’s facilities are exempt from this provision as it relates to direct care. The efficiency incentive percentages prior to the application of penalties for poor report card scores are as follows:

Direct Care – 30%Indirect Care – 60%Capital – 60%
The actual percentage incentive is based on the report card score and the following sliding scale:

Year One
Report Card Score (RCS) Allowed Efficiency %
0 - 82 100%
83 - 357 100% – ((RCS – 82) x 0.36232%)
358 & above 0%

Year Two
Report Card Score (RCS) Allowed Efficiency %
0 - 82 100%
83 - 279 100% – ((RCS – 82) x 0.50505%)
280 & above 0%

Establishes a ceiling on the efficiency rate incentive for direct care at 10% of the direct care median.

Note: The ceiling is not case-mix adjusted.

The direct care component will be excluded from the MAI limitation calculation.
Reduction of the Medicaid case-mix index (CMI) for certain residents falling into the lowest four Resource Utilization Group (RUG) categories (PB2, PB1, PA2 & PA1). The revised case-mix scores are phased-in over a two-year period. The reductions are not clinically based but are rather an economic disincentive for nursing facilities to admit such residents. When fully phased-in, the reductions represent a decrease of approximately 58% compared to the original clinically based case-mix score. The CMI changes are as follows:

RUG-III Current CMI Year One CMI Year Two CMI Year Three CMI
PB2 0.73 0.48 0.41 0.30
PB1 0.66 0.44 0.38 0.28
PA2 0.56 0.38 0.32 0.24
PA1 0.50 0.33 0.28 0.21

Note: Existing residents are grandfathered and will not have their case-mix scores reduced.

Likewise, new residents who are incontinent and have a cognitive performance score other than zero, 1 or 2, will retain the current CMI scores.

Revisions to the annual cost report submission requirements, including:
An electronic copy (ECR file) of the Medicare cost report is no longer required to be submitted. A written copy must still be submitted.

A copy of the trial balance crosswalk used to prepare the Medicare cost report is no longer required to be submitted.

A copy of the trial balance/general ledger crosswalk used to prepare the Medicaid annual report is required to be submitted.

Need additional information?
Contact your BKD Health Care advisor with questions or for assistance in assessing the impact of these changes on your organization.

201 N. Illinois Street, Suite 700
P.O. Box 44998Indianapolis, IN 46244-0998
317.383.4000
FAX 317.383.4200

Sign up to attend a Town Hall Meeting with your Legislator

Legislative Town Hall Meetings - IHCA is conducting a number of town halls around the State to generate input to build a compelling 2010 legislative agenda for long term and post acute care. As of this week, the following meetings are confirmed:

8/24/09
Sen. Sue Erringon
3:00 p.m. - 4:30 p.m.
Golden Living Center
2701 Lyn-Mar Drive
Muncie, IN 47304

8/25/09
Rep. Don Lehe
10:00 a.m. – 11:30 a.m. (CST)
Regency Place of Dyer
2300 Great Lakes Drive
Dyer, IN 46311

8/26/09
Rep. Charlie Brown
10:00 a.m. - 11:30 a.m. (CST)
South Shore Health and Rehabilitation
353 Tyler St.
Gary, IN 46402

Who should attend: Administrators, staff (including but not limited to all level nurses, activity directors, etc.), members of resident councils, social service representatives, resident families and all others with an interest in long term and post acute care issues.

Please RSVP by calling 317-616-9013 or emailing amendoza@ihca.org Don't see your community? Stay tuned. We are scheduling more town hall meetings and will update this page in the future.

***Please note this new meeting location.
For questions, please contact Amy Mendoza, director of public affairs and communication at 800-466-IHCA or amendoza@ihca.org.

Newburgh Dislocated Worker Pilot Program A Success!

Matching Dislocated Workers with Employment in Long Term Care

IHCF and Indiana Department of Workforce Development are planning statewide career fairs for dislocated workers. The Dislocated Worker Pilot Program was launched at Millers Merry Manor in Wakarusa this past spring. A second program was launched on August 7, 2009 in Newburgh. The career fair introduced long term care careers to dislocated workers in the local area. The hands-on-approach assist unemployed workers in identifying careers in long term care. IHCF will be contacting members to serve as host facility for the career fair and invite human resource representative to attend the career fair.

Next Dislocated Worker Career Fair: Coming soon!

Career fairs will be held through August and September. Check back frequently to view future dates.

Dislocated Worker Program Fact Sheet (PDF, 47kb)

For additional information, contact Dorothy Henry, Executive Director at dhenry@ihca.org or at 317-646-6406 ext. 207.

IHCA President: Massive Federal Medicare Cuts Will Hurt Seniors, Cost Jobs

Urges Indiana Congressional Delegation to Help Ensure Seniors’ Care Needs Remain
Key Priority of Health Care Reform

Indianapolis, IN – The President of the Indiana Health Care Association (IHCA) warned
that new federal Medicare cuts of up to $16 billion resulting from a recent announcement by the Obama Administration that it has put into effect a new Medicare regulation will significantly endanger Indiana seniors’ care and jeopardize the state’s already fragile economy and caregiver jobs base.

“We intend to make certain the interests of seniors remain a priority for lawmakers as they pursue health care reform in Washington, and will make sure they understand that the Medicare funding cuts on top of the Medicaid funding crisis already facing Indiana’s seniors and providers is unsustainable,” Stephen Smith, President of IHCA said.

Continued Smith: “Having now just suffered a massive Medicare funding cut of up to
$16 billion – distinct and separate from the reductions our sector has willingly and
cooperatively agreed to shoulder as part of achieving broader reform – we are alarmed
the sheer size of the cumulative cuts we ultimately suffer will be especially damaging to seniors in states like Indiana, where our Medicaid program is already under extreme strain. Medicare and Medicaid funding are inextricably linked, and the combination of cuts to both programs squeezes our local facilities in a manner harmful to Medicare beneficiaries’ care needs, detrimental to our state’s local economy, and injurious to our caregiver jobs base.”

Smith noted that Indiana nursing homes are seeing an increasingly diverse patient base, and providing a greater variety of acute care, rehabilitative and convalescent services that cannot be delivered elsewhere – care services which are now in jeopardy due to the sheer size and scope of the Medicare funding cuts. These massive funding cuts, Smith said, will undermine facilities’ ability to effectively treat this more medically complex patient population, and also put the jobs of the direct care workforce they depend upon in substantial danger.

“Achieving a sweeping health care reform bill we can all be proud of, and which will
improve the health of every Indiana resident is a necessity, not an option,” Smith
continued. Yet, protecting vulnerable seniors in the process must always remain a key
priority from which we must not deviate.”

During the upcoming August recess, Smith said, the long-term care community will ask
federal lawmakers to keep the interests of seniors and those who care for them foremost in their minds. “We intend to explain in a tangible, informative manner why it is essential for Congress, upon its return to Washington in September, to recalibrate its thinking on health care reform and scale back these enormous Medicare cuts.”

About the Indiana Health Care Association (IHCA)
The Indiana Health Care Association is Indiana's largest trade association and advocate representing proprietary, not-for-profit and hospital-based nursing home and assisted living communities, adult foster care and adult day services. IHCA's 264 member facilities care for more than 25,000 of Indiana's geriatric and developmentally disabled citizens, the majority of whom are low-income Medicaid recipients. To learn more about IHCA, visit http://www.ihca.org/.

IHCA Praises new Consumer and Workforce Satisfaction Data

Statistical Analysis Finds Consumer and Staff Satisfaction Levels Reach New Highs

Indianapolis – The Indiana Health Care Association (IHCA) praised the results of the
new 2008 National Survey of Consumer and Workforce Satisfaction in Nursing Homes
recently released by independent research firm My InnerView (MIV). The national study
found that 85 percent of consumers report their satisfaction as either “excellent” or
“good”, while 66 percent of care staff also say their facility is an “excellent” or “good”
place to work.

“As consumer and workforce satisfaction have reached the highest levels in 2008, we
applaud the efforts of care staff in Indiana’s nursing homes,” said Steve Smith, President
of the Indiana Health Care Association (IHCA). “These findings reflect the profession’s
commitment to quality-improvement initiatives and demonstrate that improvements in
the workforce are linked to consumer satisfaction and ultimately quality of care.”

States the new MIV study: “Although satisfaction levels are high, job stress is a
significant opportunity for nursing home leaders to address in order to improve nurse and
nursing assistants’ satisfaction, while meeting resident choices and preferences is one of
the top priority items for improving resident and family satisfaction.” Other highlights of
the report include data that support the view of aligning financial incentives with
organizational performance.

This month, the Indiana Health Care Foundation (IHCF) will conduct a staffing survey of
Indiana nursing homes. The survey will address job satisfaction among directors of
nursing and direct care workers such as staff registered nurses, administrative registered
nurses, licensed nurse practitioners and certified nurse assistants. Smith stressed the
goals of the Indiana survey as a continuing exercise in quality improvement.

“Our goal is to take a closer look at factors influencing job satisfaction among direct care
workers in Indiana nursing homes specifically,” said Smith. “We recognize there is
always room for improvement, especially as we look for ways to address our State’s
staffing shortage in long term care.”

About the Indiana Health Care Association (IHCA)
The Indiana Health Care Association is Indiana's largest trade association and advocate
representing proprietary, not-for-profit and hospital-based nursing home and assisted
living communities, adult foster care and adult day services. IHCA's 264 member
facilities care for more than 25,000 of Indiana's geriatric and developmentally disabled
citizens, the majority of whom are low-income Medicaid recipients. To learn more about
IHCA, visit http://www.ihca.org/.