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					           MRDD System Issues:
                Today and Tomorrow

Presented by The Ohio Department of MRDD

                       The Arc of Ohio
                  Current Issues Symposium
                        June 13, 2008

   Ohio Department of MRDD
           John L. Martin, Director
               Ohio Department of MRDD

               Phone: (614) 466-0129
                 Fax: (614) 644-5013
         Email: John.Martin@dmr.state.oh.us

Ohio Department of MRDD
           MRDD System Issues:
                Today and Tomorrow

MRDD, From The Past to Futures

Implementing the Futures Recommendations

Level 1 and Individual Options Waivers

Implementation Status of the Martin Settlement Agreement

   Ohio Department of MRDD
We’ve come a long way

T   here was a time when there was only
    one place to go for a person with mental
retardation: a large state institution.
Families were told to “just forget about
them – it will be easier that way.”

   Ohio Department of MRDD
We’ve come a long way
• As the deplorable conditions in state institutions
  were exposed, citizens and leaders took action.
• In 1950, a small group of concerned parents
  formed the Association for Retarded Children
  (later renamed The Arc).
• In 1961, President Kennedy called for a national
  program to address needs of the mentally
• Ohio responded. In 1967, Senate Bill 169
  established Ohio’s 88 County Boards of Mental
  Retardation and Developmental Disabilities.

    Ohio Department of MRDD
Today’s Challenges
• Individuals with MRDD receive better care and
  live longer and their service needs change.
• County boards report that many of their
  “emergency placements” are the result of parents
  in their eighties and even nineties no longer able
  to care for their loved ones.
• Thousands on waiting lists
• Increasing need for intensive and specialized

    Ohio Department of MRDD
Today’s Challenges
• Complicated and complex processes make
  accessing services and individual choice difficult
• County Boards concerned about losing flexibility
  over local funding
• Individuals and providers of home- and
  community-based services struggle to attract and
  retain direct care staff, with resources available
  to support them.
• State and local tax changes impacting overall

   Ohio Department of MRDD
$3.9 Billion Annual Tax Relief From
Long-Term Reforms (FY 2010)

                        Cut Income

                                                          Enact CAT

                           Tangible Tax
                           Franchise Tax

 -2.5    -2.0    -1.5        -1.0       -0.5    0.0       0.5      1.0      1.5      2.0
                                    Billions of Dollars

                                                            Ohio Department of Taxation    8
    Ohio Department of MRDD
Looking to the future
ODMRDD has established 5 System Goals:
• Less complex services, with fair and logical
  payment systems
• Good stewardship of limited resources
• Quality outcomes through a combination of
  people and processes
• Service delivery models designed in response to
  choices made by the people served, in alliance
  with community supports
• A system-wide vision developed with

   Ohio Department of MRDD
Looking to the future
Against this backdrop of progress, promise, and
pressures, Ohio’s MRDD community agreed that it
was time to take stock and to develop a strategic
plan to continuously improve its response to
individuals with mental retardation and other
developmental disabilities. Governor Strickland,
members of the 127th General Assembly, and the
MRDD community came together to created the
MRDD Futures Committee.

    Ohio Department of MRDD
  Futures Recommendations
• All Futures Sub-Committees were chaired by
  family members
• 31 recommendations
  unanimously adopted by
  a diverse group of
• ODMRDD is working to
  make changes today

     Ohio Department of MRDD
Futures Recommendation - National
Core Indicators
• Adoption of the National Core Indicators
• Ohio is the 28th state to join NCI
• Issued a Request for Proposal (RFP) to Implement
  the Consumer and Family Surveys
• Reviewed 4 applicants
• Selected The Center for Marketing & Opinion
  Research (CMOR)

   Ohio Department of MRDD
Futures Recommendation - National
Core Indicators
• Focus on desired outcomes
• Valid and reliable
• Allow Ohio to compare its performance with
  other states
• Align with CMS HCBS Quality Framework
• Support strategic system planning

   Ohio Department of MRDD
What Can We Do With National
Core Indicators Data?
• Measure system performance
• Make improvements that better
  support individuals with
  disabilities and their families
• Enable Ohio to learn about the
  strengths and weaknesses of the
  MRDD service delivery system
• Craft plans to improve quality

   Ohio Department of MRDD
Futures Recommendation -
Implementation Activities
• Establishment of six internal project teams
• Outline work steps, objectives, and products
• Development of timelines for outcomes and
• Consult with constituents along the way, ad hoc,
  as products come together

   Ohio Department of MRDD
Futures Implementation at ODMRDD
• Access and Care Management
  • Patrick Stephan - Lead
     • Waiting Lists
     • Individual Service Planning
     • Service and Support Administration

• Delivery System Management
  • Kate Haller - Lead
     • Quality
     • Planning Capacity
     • Developing Capacity

   Ohio Department of MRDD
Futures Teams
• Empowering People
  • Lisa Walsh - Lead
      • Choice
      • Control
      • Family Support

• Services Management
  • Michael Rench - Lead
      • Covered Services
      • Service Packages Design

   Ohio Department of MRDD
Futures Teams
Decision Support
  • Ann Rengert - Lead
      • Data/Fiscal/Legal Analysis

Strategic Implementation
  • Becky Phillips - Lead
      • Policy
      • Strategy

   Ohio Department of MRDD
To stay up-to-date on Futures Implementation, visit:

You can also provide your thoughts by e-mailing us:

   Ohio Department of MRDD
    Patrick Stephan, Deputy Director
     Medicaid Development and Administration
           Ohio Department of MRDD

              Phone: (614) 728-2736
               Fax: (614) 752-5303
      Email: Patrick.Stephan@dmr.state.oh.us

Ohio Department of MRDD
IO Waiver Benefit Package
A primary funding source currently in place in Ohio to assure the
health and welfare needs of individuals with developmental
disabilities. It allows people to live in and access the community,
rather than a residing in a facility-based institution.
     •   Homemaker Personal Care & Respite
     •   Adult Foster Care
     •   Transportation
     •   Adult Day Support, Habilitation and Supported
     •   Environmental Modifications & Adaptations
     •   Specialized Medical Equipment & Supplies
     •   Social Work Services
     •   Nutritional / Interpreter Services
     •   Home Delivered Meals

     Ohio Department of MRDD
Level 1 Benefit Package
Waiver program with a more limited financial scope; originally
designed to help provide assistance to individuals living at home
with their families
     • Homemaker Personal Care
     •   Respite – Institutional and Informal
     •   Transportation
     • Adult Day Support, Habilitation, Supported Employment
     •   Environmental Modifications & Adaptations
     •   Specialized Medical Equipment & Supplies
     •   Personal Emergency Response System
     •   Emergency Assistance

     Ohio Department of MRDD
Basic Medicaid Fundamentals
•   Single State Agency
•   Statewideness
•   Freedom of Choice of Provider
•   Comparability
•   Sufficiency of Amount, Scope, Duration
•   Reasonable Promptness

     Ohio Department of MRDD
Individual Options & Level 1
Waivers: Where Are We Today?
• Approximate number of individuals enrolled on
  IO Waiver: 13,400
• Approximate number individuals enrolled on the
  Level 1 Waiver: 1,700
• Approximate number of individuals WAITING
  for waiver services (combined unduplicated):
• Approximate average wait time: About 5 years

   Ohio Department of MRDD
Individual Options & Level 1
Waivers: Where Are We Today?
                                  ODMRDD Waiver Enrollment: 1998-2008




       Total Enrollees







                                 98   99   00   01   02    03    04   05   06   07   08   Level 1

  Ohio Department of MRDD
Waiver: Costs
Homemaker Personal Care
• Annual Funding Ranges 1-9 ($5,001 - $500,000)
• Prior Authorization, Ratios and Daily Billing Unit
Adult Day Array:
• Acuity Assessment Instrument, Staff Intensity Ratios, Rates &
Budget Limitations
Additional Data:
• Waiver match obligations
• Average IO Waiver Cost: $54,831 L1 Waiver: $11,792
• Total expenditures 2007 IO Waiver: $704,095,034
• Total expenditures 2007 L1 Waiver: $53,807,998.16

    Ohio Department of MRDD
How do you obtain a waiver?
• Contact your local County Board of MRDD or Job and
  Family Services to request either an IO or Level 1
  Waiver, or for placement on the IO or Level 1 waiting list
  (or both).
• Contact your County Board if you feel your situation
  warrants consideration as an emergency.
• Discuss with County Board of MRDD the “priority
  status” categories and whether or not that is a possibility.
• Continually inquire with your local County Board about
  your spot on the waiting list.

    Ohio Department of MRDD
Allocation Methodology &
Waiver Opportunities
• MRDD Medicaid Waiver Opportunities are limited.
• PICT is a process by which counties request waiver “slots” to serve
  individuals in need.
• PICT requests are completed quarterly by County Boards, with
  annual need projections being completed prior to each calendar year.
• Helps the state make sure the waivers we have are utilized to
  capacity, and rules are being followed on the local level.
• Waiver opportunities or “slots” follow statewideness Medicaid
  Standards, so counties have a specific number by which they can
  plan and operate locally.
• Individuals afforded additional opportunities via the Martin

     Ohio Department of MRDD
Waiting List & Priority Categories
• The statewide and local waiting list numbers can be staggering.

• House Bill 405: Elimination of the Long-Term Planning Registry and
  Service Substitution Lists.

• Permanence of Priority Categories: Emergencies, Individuals living at
  home with aging caregivers, children with intensive needs, Medicaid

• Futures Recommendation: “The waiting list statute needs to be overhauled
  to accommodate the needs of individuals and families in the context of the
  realities of Ohio’s unique funding streams and local services.” New
  Waiting list guidelines should include:
  - clarification of assessment requirement at the time of WL placement
  - clarification of priority categories
   - research continued need for waiting lists for non-Medicaid services
   - revise statues and administrative rule
   - investigation possibility of a DMR maintained Waiver Waiting List for
     individuals with support needs exceeding $100K annually
     Ohio Department of MRDD
What does the future look like?
• There IS hope (even if it doesn’t seem like it).

• ODMRDD recognizes the need to address the waiting list issue and
  the inflexibility of existing waiver programs (even in the tough
  budgetary climate).

• Program initiatives around children with intensive needs.

• Development of a new Medicaid Waiver Program: flexible and self-
  directed, and expected to have a wider scope of service options.

• Incorporating “Futures Recommendations” into the world of
  waivers: IE: Overhauling the Waiting List Statute.

• Simplifying the existing system and its related processes and rules.

     Ohio Department of MRDD
What does the future look like?
• Anticipated Renewal of the Individual Options Waiver in
  February, 2009.

• Waiver Allocation Increases: Additional IO Waivers
  anticipated: 2009.

• Additional Level 1 Waivers Anticipated in 2009, to go with
  recent Increase and inclusion of “replacement” capacity.

• Close monitoring of County capacity and floors, to ensure that
  waiver distribution is maximized.

    Ohio Department of MRDD
Additional 2008 Waiver Priorities
• Incorporate Futures Recommendations into potential revisions
  to Waiver related Rules, Processes and future planning.

• Finalize transition to the statewide waiver reimbursement
  system by June 30 deadline.

• Timely enrollment of the Martin-Settlement IO Waivers.

• Simplification of current IO system: Prior Authorization,
  Simplified Cost Calculation System (better assisting Counties
  to navigate the idiosyncrasies of the landscape).

    Ohio Department of MRDD
MDA: Who to contact for additional questions
•   Sara Sherman: Policy Lead: 614-752-9177: Waiver transition questions, on site-on call,
    Medicaid Buy-In, Policy or rule issues surrounding Prior Authorization, DRA, Day Array,
    On-site on call questions

•   Charlie Flowers: Prior Authorization Unit Manager: 614-466-5990: Technical Assistance
    and case specific questions related to Prior Authorization system and possible improvement
    suggestions. Questions related to statewide Autism issues

•   Jane Black: Waiver Unit Manager: 614-387-0578: Waiver eligibility and LOC issues,
    PASRR, Martin Waivers and the WMS Waiver Management system

•   Mark Smith: Medicaid Staff: 614-466-4174: Technical systems issues related to the DRA,
    2020 (or other cost-projection tool), Adult Day Array, PICT – Slots, Waiver Allocation
    (capacity & floors), ODDP

•   Mark Kleiman: Policy Staff: 614-752-8891: Medicaid Hearing issues, due process,
    Questions related to the Adult Foster Care rule, and other general Medicaid rule questions

•   Chris Miller: Policy Staff: 614-644-5519: Questions on Home Choice Program (Money
    follows the person), General Rules issues associated with Medicaid, IO & Level 1 Waivers,
    and self-determination

      Ohio Department of MRDD
Additional information and resources
             available at:

Ohio Department of MRDD
Ginnie Whisman, Assistant Deputy Director
                  Developmental Centers
                 Ohio Department of MRDD

                Phone: (740) 393-6214
                  Fax: (740) 393-6230
        Email: Ginnie.Whisman@dmr.state.oh.us

  Ohio Department of MRDD
   Additional information and resources
                available at:

  Ohio Department of MRDD

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