February 20, 2018 may be months away. But state lawmakers, Minnesota Department of Human Services (DHS) staff and people with disabilities are already preparing for the 2018 legislative session’s start. The Senate Committee on Human Services Reform, Finance and Policy met September 20 to review home and community-based services.

The issues are being reviewed now with an eye toward future legislation, said Sen. Jim Abeler (R – Anoka). “We need to learn about the issues and be in a better position for the 2018 session.”

But the work is going on with wary eyes toward Washington, D.C., where sweeping changes could come to the Medicaid program. In Minnesota, Medicaid is called Medical Assistance (MA). MA pays for many services people with disabilities and the elderly need for their everyday lives. While a proposal that would have slashed MA was set aside with last month’s demise of the federal health care legislation, changes are still possible.

“The only thing certain is that we may be looking at something different,” Abeler said.

Another certainty is this: Minnesota’s ongoing shortage of care workers looms over everything and is likely to influence any upcoming legislation. Fewer people are entering the health care workforce. Low wages for many types of direct care workers and demanding work have led to shortages.

A legislative audit of home and community-based services that was released earlier this year was discussed with DHS staff and Jo Vos of the legislative auditor’s office. These are services to help people with disabilities and the elderly to live in the community and not in institutional settings.

Alex Bartolic, director of the disability services division at DHS, said state officials agree with the findings in the report and are working to address issues raised.

Bartolic also said it may be time for DHS to revamp the entire menu of services it provides. But she also noted that DHS is dealing with a growing system. Over the past few decades, Minnesota has shifted from the highest per capita capacity of persons in institutions. About 94 percent of Minnesotans with disabilities now receive services in the community. That means people who need complex care are being cared for though the various waiver programs.

As people with disabilities and older adults are supported by thousands of providers in the community that has resulted in a person-centered system with a flexible service menu and complex rate system. It’s a balance between having people be in the most integrated setting possible, yet balancing that with how services are regulated and funded. And reform can take time.

In fiscal year 2015, $2.4 billion in MA funding was spent to provide home and community based services to about 64,000. About three-fourths of the funding covered services in residential settings.

Services can be provided through the state MA plan or waivers. There are five waivers, for brain injury, community alternative care, community access for disability inclusion, developmental disabilities and the elderly.

More than 30 percent of the funding goes toward supported living services, with 22 percent for foster homes and assisted living, and 19 percent for PCAs and home health aides.

One issue the report noted was oversight of workers. While there are consistent, basic oversight tools for PCAs that isn’t required for other types of workers doing similar tasks in clients’ homes.

“We have concerns that (DHS) has inadequate tools to monitor services provided in homes,” said Vos.

The committee and staff discussed several recommendations. One is that legislators should increase regulation over some types of direct care staff who provide services in recipients’ own homes. A second is to require DHS to regularly collect data on direct care staffing, to look at issues including wages, turnover and job vacancies.

A third recommendation is to look at the system and make it easier to understand. Vos said that payment systems vary among the waivers, and that different terms may be used to describe the same type of service. Yet the services provided may be the same or very similar. Common financial reporting, and even combining the five waivers into one were also raised as ideas.

Another recommendation is for DHS and state lawmakers to adopt a common set of financing report requirements and menu of services, combining five waivers into one.

One effort underway is new employment services that promote community-based, competitive employment, that were authorized by state lawmakers earlier this year. This plan was to go to the Center for Medicaid and Medicare by October 1.

This fall DHS is implementing a program of enhanced supports for people living in their own homes. Other changes are in development, including a new service for people who live in settings participially controlled by a service provider, training to build provider capacity in new models of service, development of plain language materials for people receiving services and their families to understand the changes in the way services are delivered, and system edits in place to prevent bill for more than 24 hours in a day. A DHS work group has convened on the billing issue.

A number of other measures are also in the works, with some requiring future legislative action. The study of consolidating four of five waivers is to be completed by January 2019. A study of individual budget methodology for disability waiver recipients is due in December 2018. Electronic service document delivery system changes are being studied by a work group, with recommendations due in January 2018. Yet another idea is for service providers to submit cost data to DHS every five years.