Montana Developmental Disabilities Program (DDP) Rate Reimbursement Project: What It Means For Consumers

By Doreen Boyer

In the fall of 2000, the Centers for Medicare and Medicaid Services (CMS) conducted a review of the Montana 1915 (c) Home and Community Based Services (HCBS) Waiver. A conclusion from the review stated, “Montana utilizes a Request for Proposal (RFP) process for contracting with providers. This process violates the freedom of choice for providers. Freedom of choice is limited for consumers because of the restriction of provider choice.”

In response to the CMS review Montana developed a corrective action plan. The plan stated that Montana would utilize its current contracting system for two more years and in that time a steering committee would be formed to initiate system changes that would offer choice to consumers and demonstrate Montana’s effort to comply with CMS rules. As a result of the committee’s work, a procedure was developed that allows any qualified person or organization to become a qualified provider of Developmental Disabilities (DD) services. The committee also approved the development of a Resource Allocation Sheet (RAS) that would identify resources that would be available to each individual recipient of Waiver services if they chose to “port” to a different provider.

Although these were substantial changes, they fell short of true choice and the CMS rules. Two major problems still persisted. First, the service rates were not uniform across services throughout the State so consumers could not always buy what they needed. This problem was identified by CMS in a follow up visit to Montana. Second, the amounts of resources identified in the Resource Allocation Sheet were not reflective of what individuals’ needs were. In most cases, providers simply divided the number of consumers they served by the amount of dollars in their contract, which might lead to individuals taking too much or too little resources with them when porting.

In the past two years, DDP worked to improve on this system by developing a published rate reimbursement system and a process to clearly identify the amount of dollars an individual would need to access community-based services. In March 2003, a meeting was held with DD providers to identify a reimbursement system. Providers and DD staff studied the options for either a cost based, or a fee (rate)-based, system. Their decision was to use a fee-based system.

In November 2003, DDP contracted with Mercer Human Resource Consulting to develop a published rate system for services and a method to allocate available resources based on the needs of individuals with developmental disabilities. The Montana Resource Allocation Protocol (mona) assessment tool was developed in an effort to provide resources to individuals. The protocol is used to determine how much money a person could receive to purchase services. Individuals will not collect “actual dollars,” but will receive an individual cost plan against which their chosen provider can bill.

Both the rates and the rates reimbursement system are due to be completed by the end of 2004 with a pilot population of approximately 160 adults slated to begin in January 2005. The pilot of the children’s system is slated to begin in March 2005. Full implementation of the rates reimbursement system may take an additional one to two years to complete.

With this new rates reimbursement system, DDP hopes to provide individuals with the information and control to give them more independence and freedom of choice. DDP will no longer be entering into contracts with individual providers, but will be entering into service agreements. Individuals receiving services from providers will enter into a contractual relationship with the provider of their choice for receipt of their services.

Questions about Rate Reimbursement Project can be addressed to the Developmental Disabilities Program, (406) 444-2995.

Doreen Boyer is the Rate Reimbursement Project Manager for the Department of Public Health and Human Services, Developmental Disabilities Program. Comments about this article can be addressed to doboyer@state.mt.us. Ms. Boyer can be reached at (406) 444-4215.