By MIKE SHIELDS

KHI News Service

WASHINGTON — The National Council on Disability today sent a letter to federal health officials urging them to postpone for a year consideration of a request by the administration of Gov. Sam Brownback to include long-term services for the developmentally disabled in KanCare.

The council, which held two days of hearings last week in Topeka as part of its ongoing study of the ramifications of Medicaid managed care, said Kansas officials need to collaborate more with developmentally disabled (DD) service providers and families before moving forward with their plans.

The council also cited concerns over delayed payments and other problems reported with KanCare and said the state should be obliged to eliminate its existing waiting list for services before being allowed to expand its relatively new managed care initiative.

“We think that concerns of the stakeholders and affected individuals and families are so significant that there should be a sufficient time period to review all the concerns that have been articulated,” said council member Gary Blumenthal, a former Kansas legislator now living in Massachusetts. “We recommend a 12-month evaluation.”

The council is a federal agency that advises executive branch agencies and Congress on disability policies. But the agencies are not bound by the council’s recommendations.
Eyes on Kansas

It is somewhat unusual for the panel, which generally makes broad or more general policy recommendations, to issue recommendations specific to a state Medicaid plan, but council officials said the national significance of what is happening in Kansas warranted the letter because the Kansas plan could be taken as a model by other states and needs to be done correctly, if at all.

“In a lot of ways, policymakers throughout the rest of the country are looking at Kansas and seeing what happens in Kansas as a potential model,” said council member Ari Ne’eman of Silver Springs, Md. “So, we focused on Kansas but we did so because we want to make sure that if managed care is done, it’s done properly and if it’s not being done properly then it’s not done.

“We were very specific in our concerns and in our recommendations and that speaks to the fact that program design is really the key to everything when it comes to the difference between a managed care framework that leads to improved outcome or one that produces potential harm. That was why we felt the need to focus on Kansas.”

Ne’eman said other states have used managed care for disabled populations but that the Kansas plan was distinct because of its scope and because KanCare was being run by “commercial insurance companies” as opposed to non-profit agencies.

Ne’eman said one of the council’s chief concerns with the Kansas plan was that it extended managed care to disabled persons in home- or community-based settings but exempted those in the state institutions.

He said that might create incentives for the managed care companies to send people with more costly or serious disabilities to the state institutions to get them off their ledgers. A longstanding goal of the council has been to end reliance on institutions such as the state hospitals.
‘Distorted’

A ranking Kansas official said the council’s letter merely repeated “distorted” reports the council heard when it was in Kansas last week without hearing all the information the Brownback administration could have provided about its planning and implementation of the program.

“Secretary Sullivan does not believe that that (the council) received an accurate picture of the managed care expansion in Kansas during the part of one day it spent hearing from the stakeholders,” said Angela de Rocha, a KDADS spokesperson. “The proceedings were set up in such a way as to paint a distorted picture of the detailed planning and consultation that has gone into including LTSS (long-term support services) for individuals in KanCare with I/DD (intellectual or developmental disabilities). This letter (sent to CMS) presents the same sorts of distortions.

“During the first (council) panel discussion, Dr. Susan Mosier and Secretary Sullivan were given no more than 10 minutes to provide an overview of KanCare and of the inclusion of LTSS into KanCare,” de Rocha said. “This was not sufficient time for the state to describe the process it has used for design, planning, implementation and evaluation of KanCare over the last three years.”

But council officials said they have been collecting information on KanCare for more than a year and that the agency’s review of KanCare and subsequent letter to CMS followed managed care guidelines first published by the council in March.

“We don’t in any way mean to take lightly Secretary Sullivan,” said council member Blumenthal. “We think he’s done an admirable job trying to pull together something that would be challenging to anyone. But this has national significance and given its size and scope we believe it is something that does really merit a cautious review.”

The council has been collecting information about Medicaid managed care nationwide and has similar hearings planned for Chicago, New York City, Tallahassee, Fla. and San Francisco.

Council members said they see potential benefits in managed care for the disabled but that it would be best done adhering to the guidelines it published in March.

The Brownback administration has been planning for at least two years to include long-term DD services in KanCare beginning Jan. 1, 2014. But officials at the federal Centers for Medicare and Medicaid Services have not yet signaled their approval of the state’s plan, which is needed if it is to move forward.

Medical services for the developmentally disabled on Medicaid already are part of KanCare. The administration’s requested expansion of the program would fold in residential and other day-to-day living supports financed by Medicaid.
Decision coming ‘soon’

The state submitted its expansion request in the form of an amendment to the so-called Section 1115 waiver that authorized the state to launch the first phase of KanCare on Jan. 1 this year. Approval of that application by CMS didn’t come until Dec. 27, 2012, only days before Kansas undertook the major remake of it Medicaid program by shifting virtually all the state’s 380,000 program enrollees into health plans run by three private insurance companies: Amerigroup, UnitedHealthcare and Sunflower State Health Plan, a subsidiary of Centene.

Federal officials recently extended the public comment period on the state’s amendment request until midnight, Dec. 24 after learning that a website used to collect comments on the proposal was malfunctioning. The site since has been fixed. CMS officials said they are not obliged by policy or law to wait 15 days after the close of public comments to render a decision as was the case for the state’s initial 1115 waiver application. The wait period does not apply for application amendments, according to CMS spokesperson Emma Sandoe.

The agency did not immediately respond to a request for comment about the council’s letter it received.

Sandoe said the agency would decide “soon” on Kansas’ application but did not provide more specific detail.

Tom Laing, executive director of Interhab, an association that represents most of the state’s Community Developmental Disability Organizations, said he thought the council’s letter and hearings that preceded it were well done and that he agreed with most of the conclusions. Interhab has been at the forefront of efforts to bar or delay the Brownback administration’s efforts to include long-term DD services in KanCare.

“I would give satisfactory marks without hesitation to the state for their work over the last several months with our members,” Laing said.

“I think the horns of the dilemma is that the decision to do this was done far in advance of having these conversations. I think there was a decision early to throw the whole Medicaid ball of wax into KanCare and that this would somehow work out and that they (administration officials) had only slight understanding of some of the complications that might arise. I don’t fault them for the work they’ve done in the last several months but there’s a lot more work to do and they might have had a different decision, if they had engaged (stakeholders) more in the planning stages. I think there was an utter lack of dialogue then and now, in the implementation stages, there’s a lot of dialogue,” Laing said.