Medicaid Community Services Win Big in RI State Budget

Rep. Marvin Abney, D-Newport, House Finance Committee Chairman, Introduces Budget Bill on House Floor - RI CAPITOL TV IMAGE

By Gina Macris

(This article has been updated.)

The Rhode Island General Assembly has enacted a new state budget of $13.96 billion that emphasizes quality-of-life issues, from education to housing to healthcare. The Senate passed the budget early the morning of June 14 and Governor Dan McKee signed it June 17.

The budget includes an increase of nearly $200 million in federal-state Medicaid reimbursements to stabilize providers of social and human services in the private sector, putting them on a par with their counterparts in neighboring states.

The plan for the fiscal year beginning July 1 marks the largest-ever single year increase to the federal-state Medicaid program. It cleared the House June 7.

Nearly $160 million of the Medicaid increase responds to recommendations of the Office of the Health Insurance Commissioner. According to a spokesman for the House leadership, another $40 million in new Medicaid funding will go to private providers of services used by the state’s child welfare agency, which has been under fire by the U.S. Attorney for a lack of community services. More than half the total cost of the Medicaid increases is funded by the federal government.

The fiscal package represents a bipartisan effort that is “about people,” said House Finance Committee Chairman Marvin Abney when introducing the fiscal package on the House Floor June 7. The budget passed the House 69-5 and cleared the Senate Finance Committee unanimously.

“This is a budget that reaffirms our commitment to education, taking care of kids, (and) those who need us most,” Abney said. The budget helps “all Rhode Islanders improve their lives,” he said.

“We continue to face a housing shortage and pressure from inflation. These are not easy fixes, and the budget doesn’t pretend they are, but it does make historic investments,” Abney said. “The collaboration of fellow legislators, advocates, and our friends in the executive branch cannot be overstated,” he said.

One way or another, Medicaid impacts the lives of 320,000 Rhode islanders, said Senate Finance Committee Chairman Louis DiPalma, D-Middletown, as he introduced the budget to the Senate Finance Committee June 11.

The shift to a “people’s budget” has been fueled by more than a decade of advocacy, most prominently involving some 4,000 adults with developmental disabilities, who were hit with drastic Medicaid cuts in 2011 which advocates say led to a civil rights consent decree in 2014.

Despite the consent decree, it took a federal court order in 2021 to move the needle on Medicaid funding – but only for providers of developmental disabilities services. Other community human services, affecting children, those suffering from addiction, the elderly, and others, continued to stagnate, with waiting lists growing, particularly for infants and toddlers needing early intervention.

In 2022, providers of nearly every Medicaid-funded service in the state descended on the State House for an hours-long hearing before the Senate Finance Committee, telling legislators that the lack of Medicaid funding threatened to destabilize the state’s entire health care and social service system. Related article here.)

That year, the General Assembly passed legislation requiring the Office of the Health Insurance Commissioner (OHIC) to conduct a comprehensive review of fair market rates for all private community-based human and social services every two years. The first report, completed in September, 2023, called for about $160 million in new Medicaid funding, not including developmental disabilities, which had just adopted a new rate structure after a court-ordered rate review.

In January, Governor Dan McKee proposed slowing down the implementation, as well as future OHIC rate reviews, but the General Assembly has turned that approach aside. DiPalma, the architect of the 2022 law calling for biennial Medicaid rate reviews, said that fully funding the Health Insurance Commissioner’s recommendations was a “critical” issue.

Weeks before the House vote, the U.S. Attorney announced new civil rights allegations linked to a lack of Medicaid-funded community services, raising the possibility of a lawsuit or a new consent decree governing the state’s child welfare system – in addition to the separate, ongoing judicial oversight of developmental disabilities services, which has cost Rhode Island hundreds of millions of dollars over the last few years. The state’s Department of Children, Youth and Families (DCYF) is talking with federal officials about a settlement in the latest child welfare case.

In the meantime, the budget will add $21.9 million to DCYF to expand home-based programs, $5.4 million for adoption and foster care, more than $ 2 million for congregate care of children, $1.5 million for a rate-setting consultant, and other expenses totaling nearly $40 million in Medicaid funding, according to House Finance Committee notes.

The new civil rights allegations, announced by U.S. Attorney Zachary Cunha May 13, say 527 children have been hospitalized for months or even years unnecessarily for psychiatric conditions that should be treated long-term at home or in more home-like settings.

 The legal framework for the 2014 consent decree affecting adults with developmental disabilities and the latest complaint is the same: the Integration Mandate of the Americans With Disabilities Act. It says people with disabilities must have access to public services in the least restrictive environment that is therapeutically appropriate. The 1999 Olmstead decision by the U.S. Supreme Court re-affirmed that mandate, saying the least restrictive environment is presumed to be the community.

 In the case of the 2014 consent decree, federal oversight of the developmental disabilities system will continue until 2026.

Over the past year, the state has begun implementing a new rate model and administrative structure intended to help adults with developmental disabilities get jobs and participate in more community activities. A court-appointed monitor says that “much has changed,” but that the state must intensify its efforts if it is to achieve full compliance with the consent decree in the next two years.

Not all the new services promised by the state are actually available, and those that exist, like add-on employment services, are difficult to obtain, according to the monitor, A. Anthony Antosh.

The result: the Division of Developmental Disabilities is leaving money on the table. The House Finance Committee cut more than $38 million from the Governor’s original budget request for developmental disabilities in the next fiscal year, on the recommendation of the May Caseload Estimating Conference.

The governor had asked for nearly $462.4 million for privately-run developmental disabilities in Fiscal 2025, but the Caseload Estimating Conference recommended about $423.9 million.

Similarly, the budget cuts $39.6 million from the governor’s request of $442.8 million for privately-run services to close out the current fiscal year June 30. The Caseload Estimating Conference recommended $403.2 million.

(The recommendations do not include a separate state-run group home system for adults with developmental disabilities – not affected by the consent decree - which is funded at roughly $32.5 million a year.)

The Caseload Estimating Conference makes projections for developmental disabilities - and other Medicaid categories - based on current costs. But the court monitor, Antosh, says the numbers reflect problems with the implementation of the consent decree.

For example, agencies have been paying for professional services, like nursing, but haven’t been able to get reimbursements from the state because a new billing system cannot yet handle their submissions, he said in a report to the court. The agencies must be allowed to bill retroactively to capture those reimbursements, he said.

In a recent report, Antosh said a new process for building individual budgets based on a thoughtful, personalized three-step assessment process has not yet come together. The state also lacks the independent facilitators who are supposed to help eligible persons get the services they need, Antosh said.

The budget plan includes $1.9 million in the Executive Office of Health and Human Services for 18 state social workers to act as independent facilitators during the next fiscal year, while a statewide approach to conflict-free case management is developed for all Medicaid recipients of home and community-based services.

Antosh in recent months has submitted detailed reports to Chief Judge John J. McConnell, Jr. of the U.S. District Court, who will hear the case Thursday, June 13, at 11 a.m.

The public can access the remote hearing by following the instructions on the calendar page of the court here.

McKee: RI DD Services Need $510.6 Million

By Gina Macris

RI Governor’s FY 25 Budget Proposal-

In a budget plan largely driven by the federal court, Rhode Island Governor Dan McKee has proposed $510.6 million in overall developmental disabilities spending for the fiscal year beginning July 1, about $41.5 million more than the General Assembly enacted for the current fiscal year.

Roughly 55 percent, about $283.4 million, of the proposed developmental disabilities budget would be reimbursed by the the federal-state Medicaid program.

At the same time, McKee seeks to close a projected deficit of $28.3 million in the current budget of $469.1 million as the state tries to integrate adults with developmental disabilities into their communities to comply with a 2014 consent decree with the Department of Justice (DOJ).

Much of the shortfall reflects upward cost adjustments made by the Caseload Estimating Conference (CEC), a budget-planning panel which meets twice a year, advising the governor in November and the General Assembly in May.

McKee also would add $2.9 million to the current budget, and $1.1 million in the next one, for “conflict-free case management,” not only to adhere to Medicaid regulations but to comply with the consent decree. Almost all that funding would come from the federal government.

State social workers from the Division of Disabilities will be assigned to check in monthly with those receiving services and their families to determine if their needs are being met, according to a BHDDH spokesman.

It is not clear whether – or how - this arrangement meets the expectations of an independent court monitor overseeing the consent decree changes. The monitor, A. Anthony Antosh, hasn’t issued a report since last August. Antosh has called for “independent facilitators” to help each individual develop a purposeful program of services and to keep track of how the plan works out.

Developmental disabilities programs account for more than $7 out of every $10 spent at the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), which would get a total of $706.3 million in McKee’s proposal. McKee’s proposed budget for all state spending in the new fiscal year is nearly $13.7 billion.

The latest proposal represents nearly a third more funding for developmental disabilities than the $339.3 million the General Assembly approved just three years ago, in the spring of 2021.

Much of the investment, in recent years, has been used to hike wages for caregivers and their supervisors, for education and training, and for the development of innovative approaches to supporting adults with developmental disabilities.

In three steps since July, 2021, the state has raised the pay for direct care workers by about 49 percent, from $13.18 an hour to a minimum of $20 an hour, in keeping with orders from Chief Judge John J. McConnell of the U.S. District Court, who has been monitoring the state’s efforts to meet the requirements of the consent decree since 2016.

McConnell found that, apart from the impact of the Covid-19 pandemic, historically depressed wages had led to an exodus of workers that prevented the state from offering employment and other services in the community as promised in a 2014 consent decree.

Beginning last July, the $20 minimum hourly rate for workers has been wrapped into a new reimbursement system for private agencies intended to accurately evaluate the needs of individuals, allow them bigger spending limits to get employment and other supports, and to implement administrative changes promoting integration in the community.

The ultimate impact of higher funding on the lives of adults with developmental disabilities remains to be seen. A decade after the state adopted an “Employment First” policy as part of the consent decree, the governor’s figures say that 24.8 percent of the population protected by the consent decree is working in the community, far short of the target 73 percent.

In November, BHDDH told the CEC that private service providers still don’t have the number of workers they need to offer employment-related services and community-based supports for all who want them. A BHDDH report called the shortage “critical.”

 Still, the state’s eye-opening investment in historically underfunded services during the last few years has begun to show results. While a big staff shortage remains, private agencies are beginning to see improvement in their ability to attract new workers.

The recent pay hikes, along with support from a statewide workforce initiative, helped private providers add 274 direct support staff between January and September of 2023, BHDDH officials reported in November.

McKee’s proposal for Fiscal Year 2025, which begins this July, includes nearly $462.4 million in reimbursements to the three dozen private agencies, or subcontractors, who serve as the backbone of the service system the state relies on to carry out the requirements of the 2014 consent decree.

These reimbursements also cover the cost of one-person programs managed by so-called “self-directed” individuals or families. The number of self-directed programs has grown to more than a quarter of the caseload of about 4,000 persons, in part because of the staff shortage at private agencies. Individuals and families, however, report the same kinds of problems finding qualified caregivers as the agencies, especially when it comes to securing employment-related services.

A separate line in the budget would allocate $15.6 million for other costs related to private services, according to a spokesman for the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH).

These expenses include the salaries of state social workers and administrators assigned to clients of the private providers, as well as human resources support, building maintenance, information technology support, and contracts for electronic records and for education and training provided by the Sherlock Center at Rhode Island College, the spokesman said.

The state also maintains its own network of group homes, which McKee would fund with $32.6 million in the next fiscal year.

All together, these budget categories add up to nearly $510.6 million.

No additional wage increases are planned for the fiscal year beginning July 1, except for those who provide in-home services to adults with developmental disabilities and were included in a comprehensive Medicaid rate review conducted by the Office of the Health Insurance Commissioner (OHIC). For the in-home workers, the governor’s budget seeks about $844,000. The final OHIC report, issued last September, said that the developmental disabilities workforce will be part of the next rate review in two years.

Consent Decree Drives Proposed Hike In RI DD Spending

By Gina Macris

Rhode Island Governor Dan McKee would add more than $30 million to developmental disabilities spending to raise starting pay for direct care workers to $20 an hour, hike dozens of reimbursement rates to private service providers, and add ten new staff to help implement a 2014 consent decree.

The pay increase, costing $29.9 million in federal-state Medicaid funding, would be the third annual hike intended to help private agencies and the so-called “self-directed” population managing their own service programs. The wage increase would comply with a federal court order that dates back two years.

In 2021, when the starting wage for direct care workers was $13.18 an hour, Chief Judge John J. McConnell, Jr. ordered the state to raise wages to $20 an hour by 2024, calling a lack of staff the single biggest barrier to implementing the day-to-day requirements of the consent decree, albeit not the only one.

In 2022, with pay raised to $15.75 an hour, the Rhode Island system added 106 new direct care workers from January through June.

On July 1, 2022, the starting pay increased again to $18 an hour, and the state, prodded by the court, launched a workforce initiative to recruit candidates for direct care jobs. In September alone, the system filled 146 vacancies, according to data collected by an independent court monitor.

Yet there were still 693 vacancies in some three dozen private agencies and as many as 1,000 job openings among self-directed consumers and families, the monitor reported in early November.

overview of proposed DD spending - RI Department of Administration

In all, McKee seeks a total of nearly $417.4 million for all developmental disability services in the fiscal year beginning July 1, including slightly more than $385 million for the privately-run system, the backbone of consent decree compliance. That figure for private agency and self-directed services represents a bump of about $32.2 million over the current allocation of about $352.9 million.

A parallel network of state-run group homes would get $32.4 million in the next budget, or almost $1.8 million more than the current funding level of $30.8 million.

The budget for the next fiscal year, July 1,2023-June 30, 2024, will finance the state’s final push to comply with the consent decree before the deadline on June 30, 2024.

The state agreed in 2014 that by mid-2024, it would eliminate sheltered workshops paying sub-minimum wages and move away from isolated day care centers. Instead, there would be a de-centralized network of individualized services enabling adults with developmental disabilities to become integrated in their communities.

The Department of Justice (DOJ) has said that Rhode Island will likely miss the 2024 deadline if it moves at the current pace. The DOJ cited numerous factors contributing to a lack of services, particularly the individualized services in the community that are the cornerstone of the consent decree. A far-reaching federal court order issued Dec. 6 lists some 50 requirements that must be completed by the deadline on June 30, 2024.

McKee wants the new consent decree implementation staff on board as early as possible.

A spokesman for the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) said the department hopes to complete the hiring process by the fourth quarter, which runs from April through June. The cost for these added workers would be $203,275 for the first full year, taking into account federal Medicaid reimbursements and savings from staff turnover in other positions, according to McKee’s executive summary of the spending plan.

Eight of the ten positions will be permanently added to the Division of Developmental Disabilities (DDD), the BHDDH spokesman said.

The DDD jobs include:

• an “interdepartmental project manager”

• a “chief of staff for development training and continuous quality improvement”

• ·an “associate administrator for community services”

• five positions promoting community development as it relates to adults with developmental disabilities

The salaries will range from $66,162 to $95,552 a year, the BHDDH spokesman said.

Two other employees not attached to BHDDH will help implement an outside consultant’s recommendations for reimbursement rates for private providers.

Undertaking a rate review itself was part of a court order issued in October, 2021. Consultants disclosed preliminary recommendations last September that called for increases ranging from about 25 percent to 97 percent in dozens of reimbursement categories to private providers.

But McKee said in an executive summary of the budget that the consultant’s report is “currently under review and may further increase the recommended amount of financing” allocated to the private developmental disabilities system.

Among other actions, the Dec. 6 court order requires the state to identify successful pilot programs promoting integration that have been developed by private service providers during the past year and make those programs available to all those who want them, regardless of the way consultants have structured reimbursements to the private sector.

The consent decree has brought more transparency to budgeting by generating pressure on the General Assembly to include adults with developmental disabilities in the biannual caseload estimating conference, a public process used to project the state’s obligations for public assistance, like food stamps. Developmental disability costs were added in 2021.

The most recent caseload estimating conference, in November, projected there will be $8.5 million less in reimbursements to private service providers than budgeted for the current fiscal year because the population is expected to use fewer support services than initially budgeted.

McKee’s proposal takes the caseload estimating conference projections into account, as well as other related costs, in reducing developmental disabilities services by about $4.4 million, from about $352.9 million to about $348.5 million, in the current fiscal year.

The caseload estimating conference also highlighted the fact that consumers and families often must appeal individual budget allocations to get needed services – a feature of the current reimbursement system which the federal court has cited as a weakness.

Projections for the current fiscal year include $22.8 million in successful appeals, or $5.8 million more than budgeted. An independent court monitor has said consumers should not have to make lengthy appeals to get the individualized services to which they are entitled.

The consent decree draws its authority from the Supreme Court’s Olmstead decision, re-affirmed the Integration Mandate of the Americans With Disabilities Act, requiring public services for all persons with disabilities to help them lead regular lives in the their communities.

Developmental disabilities funding makes up about two thirds of the overall BHDDH budget, which is currently funded at about $597.1 million. McKee would raise the BHDDH total to about $619.6 million in the next fiscal year, with more than half the revenue coming from federal Medicaid reimbursements.

RI House To Vote On Pay Hikes For RI DD Workers

UPDATE: On June 24, the House passed a $336.7 million developmental disabilities budget as recommended by the Finance Committee. It is part of an overall overall $13.1 billion spending package proposed for the fiscal year beginning July 1 that now goes to the Senate.

By Gina Macris

Rhode Island would add an estimated $2.53 an hour to entry-level pay for caregivers of adults with developmental disabilities in the proposed state budget that it is headed for a vote in the House Thursday, June 24. But it’s not clear if the wage hike will be enough to attract needed workers.

The proposed wage increase, from an estimated $13.18 to $15.75 an hour, resulted from months-long, court-ordered negotiations intended to develop a three-year plan to strengthen Rhode Island’s private developmental disability system so it will enable the state to comply with a 2014 civil rights consent decree.

The proposed wage package also includes a $3.58 hourly increase for supervisory personnel, from $18.41 to an estimated $21.99 an hour.

The House Finance Committee accepted the negotiated rates during a June 17 vote on the overall budget for the fiscal year beginning July 1. But it rejected Governor Dan McKee’s plan to privatize the state’s own parallel group home system, saying 50 state jobs that would have been eliminated should be restored to the state payroll.

In all, the state and privately-run developmental disabilities systems would get nearly $336.7 million in the fiscal year beginning July 1, an increase of roughly $32.7 million over the current budget of $304 million.

The privately-run system would get a total of $297.6 million, or about $37.2 million more than the current allocation of $260.4 million, according to figures from the Office of Management and Budget (OMB) and the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH).

The higher total reflects the cost of the pay hikes, $39.7 million in federal-state Medicaid funding, including the redirection of $13 million of a $15 million “transition and transformation fund” the McKee had administration originally had proposed for court-ordered system reforms to comply with the consent decree.

Chief Judge John J. McConnell, Jr. of the U.S. District Court had ordered the state to come up with a three-year plan by June 30 that would spell out what it intends to do to comply with the consent decree by the end of the decade-long implementation period June 30, 2024.

In a recent report, an independent court monitor told the judge that the second and third years of the plan were not discussed during the recent negotiations, and he recommended that the state continue to meet with private service providers and others on a weekly basis to discuss unresolved issues.

In a recent hearing before the House Finance Committee’s Subcommittee on Human Services, the director of the Division of Developmental Disabilities, Kevin Savage, said the state has a “difficult” relationship with the federal court.

While providers have called the raises a significant step, they say they do not believe that the new rate of $15.75 will affect their worker shortage when Massachusetts and Connecticut are paying more.

On July 1, minimum wages in Connecticut will increase to $16.50 an hour for private-sector direct care workers in the first year of a two-year contract between that state and the Service Employees International Union (SEIU). The rate will jump to $17.25 on July 1, 2022.

Massachusetts will pay direct care workers at privately-run agencies a minimum of $16.10 an hour beginning July 1, the final year of a three-year contract with another branch of the SEIU, according to a salary schedule on a Massachusetts state website related to “personal care attendants.”

Tina Spears, executive director of the Community Provider Network of Rhode Island, has said in recent weeks that she has recommended data be collected on hiring and retention to enable the court to gauge whether the wage hikes help providers expand their workforce.

As it now stands, the private system lacks about 37 percent of the workforce it needs to support individuals in jobs and non-work activities in the community as required by the consent decree and the Integration Mandate of the Americans With Disabilities Act, according to a recent report made to the court.

In other changes, the House Finance Committee moved up by one year the date for including the developmental disabilities caseload in an important budget-planning exercise, the Caseload Estimating Conference. That means the change would take effect in 2021, instead of 2022.

Judge McConnell has ordered that the developmental disabilities caseload be part of the discussion at the Caseload Estimating Conference beginning November of this year to bring transparency and consistency to budgeting for these services.

House Finance recommended the Executive Office of Health and Human Services give assistance to the BHDDH to prepare the caseload data for presentation at the November conference.

The McKee administration never explained why it originally proposed that the change be made in 2022.

In another court-ordered reform, an OMB spokesman confirmed that the allocation for the privately-run system of services contains $6.8 million to fully fund annual authorizations that set an individual spending limit for each person receiving developmental disability services.

For the last decade, the authorizations have been available on a quarterly basis. Any amount not utilized within a particular three-month period cannot be carried over to the next quarter. And the fee-for-service reimbursement system now in place means that providers cannot bill for those who do not participate on a particular day, for whatever reason, even though the agencies may incur the same costs for staffing.

Providers and service recipients and their families alike say that annual funding will allow them greater flexibility in planning their programs.

RI House Finance Committee To Air Governor’s New Plan To Raise DD Wages

By Gina Macris

Rhode Island Governor Dan McKee has asked the General Assembly to fund hourly pay rates of $15.75 for frontline workers serving adults with developmental disabilities and $21.99 for supervisory personnel.

The House Finance Committee will hold a public hearing on the proposal Thursday, June 10, at the conclusion of the full session of the House, which is not set at a fixed time but usually occurs sometime after 5 p.m.

The budget amendment aims to offer competitive wages to direct care workers in compliance with a 2014 civil rights consent decree, according to a June 7 memo from Jonathan Womer, Director of the Office of Management and Budget, sent to the chairmen of the House and Senate finance committees.

The wage increases would cost a total of $26.7 million more in federal-state Medicaid funding than McKee had originally proposed for the privately-run developmental disability service system in the fiscal year beginning July 1 – nearly $7.8 million in additional state revenue, and almost  $19 million in federal reimbursements.  

McKee also would redirect $13 million in Medicaid funding to the wage package, including $9 million in state revenue and $4 million in federal funding. That means the entire wage package would cost a total of $39.7 million, with federal reimbursements accounting for well over half that figure. Entry-level workers in the privately-run system are now paid about $13.18 to $13.40 an hour, according to various providers.

The $13 million re-directed to wages would come from a $15 million “transition and transformation fund” for initiating systemic reforms to help the shift to integrated, community-based services required by the consent decree. McKee’s proposal would leave the innovation fund with $2 million. (A recent report of an independent monitor to the U.S. District Court recently criticized an earlier state plan that would have eliminated the innovation fund, putting all the $15 million into wages.)

In another matter aimed at consent decree compliance, the proposed budget amendment would move up the date for including the caseload of the privately-run system of developmental disabilities in the semi-annual Caseload Estimating Conference used by the executive and legislative branches of state government to plan state budgets.

The amendment would add these caseload numbers to deliberations beginning November, 2021, as ordered by the federal court, instead of November, 2022., as had been originally proposed by the McKee administration. The inclusion of the developmental disabilities caseload is intended to ensure predictable, consistent funding for these entitlement services funded by the Medicaid program, according to the court order.

Because of COVID-19 public health restrictions, the Finance Committee will not take testimony in person. Instead, it has established rules for those who wish to submit written testimony in advance or pre-register to be called on the phone to submit verbal testimony.

According to the agenda for Thursday’s hearing:

“The meeting will be televised live on Capitol Television, which can be seen on Cox Channels 15, and 61, in high definition on Cox Channel 1061, on Full Channel on Channel 15 and on Channel 34 by Verizon subscribers. It will also be live streamed at http://rilegislature.gov/CapTV/Pages/default.aspx

“WRITTEN TESTIMONY: Written testimony is strongly encouraged and may be submitted via HouseFinance@rilegislature.gov   Indicate your name, bill number, and viewpoint (for/against/neither) at top of message. Due to high volume, clerks are not screening this inbox for verbal testimony requests. This inbox is for written testimony only. DEADLINE: Written testimony should be submitted no later than three (3) hours prior to the posted meeting time. Every effort will be made to share written testimony submitted before the deadline with committee members prior to the hearing. Testimony received after deadline will be sent to committee members and posted to the website as soon as possible. For faster processing, it is recommended that testimony is submitted as a PDF file. Testimony will be posted on the General Assembly website, http://www.rilegislature.gov/Special/comdoc/Pages/HFIN.aspx

“VERBAL TESTIMONY: Due to the extremely high volume of requests, and in order to accommodate as many constituents as possible, please take note of the revised procedure for verbal testimony:

“DEADLINE: Requests for verbal testimony must be submitted via the link, by 4:00 PM on Wednesday, June 9, 2021. For verbal testimony requests, CLICK HERE  

“Verbal testimony accepted on any bill scheduled for "Hearing and/or Consideration" only The committee is unable to designate a specific time that you will be called. In the event you are unavailable when called, witnesses are urged to submit written testimony. Christopher O'Brien Committee Clerk 222-6916 HouseFinance@rilegislature.gov  “

RI General Assembly Will Handle Court-Related DD Issues DD Issues In Regular Budget Talks

By Gina Macris

The pace of discussions for complying with a court-ordered overhaul of Rhode Island’s developmental disability system is expected to pick up as early as next week, when newly elevated Governor Daniel McKee rolls out his budget proposal for the fiscal year beginning July 1.

McKee was sworn in March 2, replacing Gina Raimondo, who resigned as governor after clearing final hurdles in Washington, DC to become Secretary of Commerce. Raimondo’s office said in mid-January that McKee, then Lt. Governor, would be responsible for submitting the budget proposal to the General Assembly.

It remains unclear to what degree, if at all, the proposed state budget will incorporate additional money for initial steps toward compliance with a federal court order enforcing a 2014 civil rights agreement.

While uncertainty about funding hovers, court-ordered discussions organized by the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) have been underway since last August to develop a path forward for providing services that will encourage integration of adults with developmental disabilities in their communities, in accordance with the 2014 consent decree and the Americans With Disabilities Act.

A recent report to Chief Judge John J. McConnell, Jr. of the U. S. District Court indicates short-term recommendations are taking shape to address some of the 16 points the judge laid out in a reform agenda last summer.

He gave the state until June 30 to develop a three-year implementation plan that will achieve full compliance with the consent decree by 2024.

Representatives of the House and Senate leadership participated in some court-ordered reform talks until McConnell issued an order Jan. 6 which said the three-year plan must include these specifics:

• a $20 minimum wage for direct care workers by fiscal 2024.

• Incorporation of the developmental disabilities caseload in the formal process for estimating the state’s public assistance obligations for budget calculations, beginning this year.

On March 3, House Speaker Joseph Shekarchi and Senate President Dominick Ruggerio issued a new statement on how they will handle legislative issues raised by the reform efforts:

“Specific issues will be analyzed and discussed in legislative committees as part of the public hearing process on pending legislation as well as the upcoming state budget.”

The two leaders continued: “The members of the General Assembly care deeply about individuals with developmental disabilities and ensuring a strong continuum of care, and the Senate President and House Speaker believe that we have an obligation as a society to provide strong services and supports for all vulnerable Rhode Islanders.”

The leadership had withdrawn from reform talks out of concern that their representatives’ participation could be perceived as tacit approval of change outside the legislative process, according to separate letters sent to McConnell Feb. 3.

Shekarchi’s and Ruggerio’s statement did not specifically mention the direct care worker wages or making the developmental disabilities numbers part of the twice-yearly Caseload Estimating Conference, the budgeting tool used by the governor and the legislature.

Development of a new approach for determining how to support the individualized plans of the developmentally disabled population is at the heart of the overhaul. The existing fee-for-service system was designed 10 years ago for congregate care, where one or two staff members could oversee as many as ten clients in a day care center or sheltered workshop. The U.S. Department of Justice found that model violated the ADA’s Integration Mandate.

In November, McConnell heard testimony that the current funding ceiling for the private provider system, roughly $268.7 million in federal/state Medicaid money, will not support integrated services, which are much more labor-intensive — and thus, more costly — than congregate care. The cost of correcting the non-compliance could increase the developmental disabilities budget by nearly 50 percent, according to one estimate.

Because of the uncertainty over funding, five workgroups organized by BHDDH are focusing on short-term changes that can ease administrative burdens on providers and make the state bureaucracy more user-friendly for the individuals served and their families, according to a progress report submitted to McConnell at the end of February.

According to the report, BHDDH expects to have detailed information by March 31 on:

• shifting from quarterly to annual per-person budget authorizations

• streamlining dozens of private provider billing codes, many of which require documentation of staff time in 15-minute increments for each client served

• simplifying the process of writing each client’s annual service plan “to reduce repeated questions, frustrations, and errors requiring correction and intervention.”

The report recommends adding a second assessment or new questions or criteria to improve the accuracy of the standardized Supports Intensity Scale-A, (SIS-A) interview, used to determine service needs and funding levels.

Improved assessments would reduce reliance on appeals. Interviewers also need training on cultural differences, it said.

Additional recommendations include:

• a training program for parents on how to approach the SIS-A, which has been the subject of frequent complaints over the years from parents

• clarification of the process for appealing funding determinations made as a result of the SIS-A, and developing ways to more quickly resolve appeals

• consolidation of separate applications for Medicaid and for Medicaid-funded services into one process

• a request for a waiver from the Centers for Medicare and Medicaid Services for Medicaid eligibility redeterminations for persons with developmental disabilities, who have life-long conditions.

The report said long-term revision of the fiscal and reimbursement system will be implemented by December, 2022.

The workgroups developing the recommendations include both state officials and representatives of the community, including individuals who themselves receive services, families, advocates, and service providers.

The groups’ recommendations are reviewed by the appropriate department-level directors and other key officials, according to the report.

Once final recommendations are analyzed and decisions made by the state, a “cohesive workplan” that will be submitted to McConnell on or before June 30 as required by an order the judge issued last July 30, the report said.

RI House And Senate Withdraw From Budget-Related Consent Decree Talks

By Gina Macris

Both the Rhode Island House and Senate have withdrawn from negotiations on a three-year budget plan to overhaul the state’s developmental disabilities system and comply with the Americans With Disabilities Act (ADA).

The development of such a plan had been recommended by an independent federal court monitor as part of a fiscal analysis he submitted in November to Chief Judge John J. McConnell, Jr of the U.S. District Court. McConnell oversees the state’s efforts to get into compliance with a 2014 consent decree in which the state agreed to correct violations of the ADA by 2024.

Members of the House and Senate joined the talks in December, but the leadership of both chambers of the General Assembly decided to withdraw after McConnell made the development of the three-year budget plan the topic of a court order Jan. 6.

Dominic Ruggerio

“We are concerned that continued involvement of the Senate could be perceived as tacit approval of the entire body without the proper processes that allows for meaningful member input,” Senate President Dominic Ruggerio and Majority Leader Michael McCaffrey said in a Feb. 3 letter to McConnell.

The House used similar language in a separate letter.

Ruggerio and McCaffrey wrote, “We appreciate the work of the Court and the process by which you are moving to identify and operationalize solutions to accomplish the goals of the consent decree.”

“We anticipate that the Court will order the state to undertake a course of action, and at that time, in our role as the appropriating body, we will further engage in this process,” the Senate leadership told Judge McConnell.

Last July, McConnell ordered an overhaul of the entire developmental disabilities service system to end segregated care and encourage the integration of individuals with intellectual challenges in their communities.

In response to that July order, representatives of the state’s developmental disability agency began working with families, providers, and advocates on a 16-point agenda for reforming the way services are delivered and the rules for reimbursing the private agencies which provide direct care.

McConnell’s order on Jan. 6 focused on the budgetary implications, memorializing the main points of the monitor’s analysis, including a requirement that the state raise the wages of direct care workers to $20 an hour by Fiscal 2024.

In the same order, McConnell also said the actual costs of developmental disabilities services must be included in a state budgeting procedure known as the Caseload Estimating Conference, which allows the state to get a better handle on its financial obligations for entitlement programs.

Joseph Shekarchi

In a statement responding to a request for specifics prompting the withdrawal, Shekarchi, newly elected Speaker of the House, said, “It would be best to answer these questions with an overall clarification that the action by the House is not a repudiation of any of the specific ideas being discussed.“

When the House was invited to join talks in December, the leadership expected that its representatives would participate in discussions about issues of concern for service providers and options for what might be included in the Governor’s upcoming budget. House leadership “was happy to have someone included,” Shekarchi said.

Because the Jan. 6 order contained “much more prescriptive policy remedies than expected, the House felt that further participation might be perceived as delegation of its legislative authority,” the statement said.

It was out of an abundance of caution that the House withdrew, he said.

The Senate leadership’s letter said it was “unclear if the Senate’s inclusion was designed to guide discussions and outcomes or merely for observation.”

Ruggerio and McCaffrey said “the Senate values continued dialogue and looks forward to reviewing any proffered solutions in an open, public committee process.”

Similarly, the letter from the House leadership said they encourage continued dialogue and “are eager to have one or more of our committees review potential solutions in an open and public process.”

Individual Senators may continue to participate in the current talks, but are acting on their own behalf and do not represent the Senate as a body, Ruggerio and McCaffrey said.

Sen. Louis DiPalma, D-Middletown, has attended the negotiations and is widely known as an advocate for the integration of adults with developmental disabilities.

McConnell, meanwhile, has scheduled a private conference Feb. 11 with the monitor, Antosh, and lawyers representing the U.S. Department of Justice, the state, and several service providers.

RI Faces High Cost For Fixing DD ADA Violations

By Gina Macris

After funding services for adults with developmental disabilities below their actual costs for nearly a decade, the state of Rhode Island is about to experience sticker shock.

The system of private agencies that provides most services for adults with developmental disabilities is on the verge of collapse, by all accounts, and a federal judge has given the state until Dec. 18 – five days from now – to come up with the money to keep it afloat until the next fiscal year.

The state also is under court order to devise and execute a plan for strengthening the system during the next three years so it can comply with a federal civil rights agreement that requires Rhode Island to integrate adults with developmental disabilities into community life by 2024. With the judge ready to use his power to enforce the consent decree, those costs could increase spending on developmental disability services by a third or more in the next several years.

Last month, a federal court monitor addressed the short-term fiscal gap by suggesting that the state release $2 million a month in unspent funds already allocated to developmental disabilities simply to keep the agencies’ doors open over the next six months. The COVID-19 pandemic has forced agencies to shrink services and drastically reduce billing.

Judge John J. McConnell, Jr.

In a recent hearing before Chief Judge John J. McConnell, Jr. of the U.S. District Court, a spokeswoman for service providers took a different approach, saying the state needs to immediately raise direct care pay, now an average of $13.08 an hour, to enable the private agencies to recruit and retain employees during the pandemic.

Roughly two thirds of these essential workers are women and more than half are people of color, according to the trade association spokeswoman.

A recently-completed report from the association, the Community Provider Network of Rhode Island (CPNRI), fleshes out projected costs:

• An hourly increase of $2.32, to $15.50, would require nearly $44.1 million a year, or 16.4 percent more than the state has currently budgeted.

• A hike to $17.50 would mean an additional $79.8 million, or a 29.7 percent increase in the annual budget

• A $20 hourly rate would add $124.5 million to the budget. That would amount to a 46.4 percent increase in spending.

The report, “A System in Crisis,” said employers need to be able to offer $17.50 immediately to get job applicants in the door during the pandemic. In Fiscal 2022, which begins July 1, the rate should be increased again to $20 an hour.

Monitor’s Calculations More Limited In Scope

The monitor, meanwhile, agrees with the need for pay hikes, although he would allow the state more leeway on the timeline. In his latest report, filed with Judge McConnell Nov. 30, the monitor, A. Anthony Antosh, said the state should raise hourly wages to $17.50 “as quickly as possible” and to $20 by Fiscal 2024, which begins July 1, 2023.

A. Anthony Antosh

Antosh’s fiscal analysis focuses primarily on the changes needed in the final three years of the consent decree. He said there is consensus among various stakeholders with whom he has consulted that staffing and fiscal issues are the two main concerns in implementing the 2014 civil rights agreement.

“The state budget deficit resulting from the COVID-19 pandemic significantly complicates any fiscal analysis and any decision-making about budget planning,” he said.

Antosh makes no specific dollar recommendations but says that figures should be negotiated with provider agencies in a three-year budget plan to be completed in time to begin in the next fiscal cycle on July 1, 2021. He emphasized that the agencies provide 83 percent of the services necessary to support those protected by the consent decree.

Antosh said an ongoing review of the entire fiscal and reimbursement system, itemized in a 16-point court order issued by McConnell July 30, should be complete by June 30, 2021.

He also recommended that steps be taken now to make sure that the specific costs of a strengthened developmental disability system are acknowledged when future state budgets are being developed.

For example, the data on caseloads provided monthly by the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) to the General Assembly should be included in the Caseload Estimating Conference used to determine human service needs in the overall state budget. That is also one of the final recommendations of the “Project Sustainability Commission,” a a special legislative commission headed by Staite Sen. Louis DiPalma, D-Middletown.

While not acknowledging the actual costs, which pay for entitlement services under provisions of the Americans With Disabilities Act, the General Assembly has often criticized the state’s developmental disabilities system for running over budget.

The governor typically relies on the November caseload and revenue estimating conferences to draw up the budget that is submitted to the General Assembly in January. The legislature, in turn, relies on more finely tuned caseload and revenue estimates in May to finalize a spending plan for the next fiscal year.

Monitor’s Numbers “Illustrate” Solutions

Antosh’s report includes five sets of fiscal projections that can best be described as starting points for discussion rather than cost estimates for system-wide change. For reasons related to the language of the consent decree, the monitor’s numbers cover individuals who were identified in confidential documents between 2013 and 2016 and today make up about 67 percent of the entire population with developmental disabilities.

Antosh said the tables of projections and descriptions of the associated costs “illustrate” various options in reconfiguring daytime services for the 67 percent.

The most comprehensive “illustration “ of the cost of re-inventing daytime employment and leisure activities for the specific portion of the population protected by the consent decree would add $35.6 million to the budget in Fiscal Year 2022, which begins next July 1, Antosh said. An additional $14.9 million would be needed in Fiscal 2023 and $15.8 million extra would be added in Fiscal Year 2024.

In addition to protecting a particular class of people, the consent decree is supposed to lead to a system-wide transformation. And state officials have made clear that they intend to include all people eligible for developmental disability services in a reformed system, not just those identified at the time of the consent decree.

The three increases projected by Antosh add up to about $66.3 million a year in three years’ time. Antosh said the increases need not all come from Medicaid funding but draw on a variety of other public and private sources.

The current annual approved budget for the private service providers is about $268.7 million in federal-state Medicaid funds, although the providers’ ability to bill for reimbursement has shrunk since the start of the pandemic.

Actual spending on privately-run services was about $240.8 million in the fiscal year that ended June 30, 2019, according to state budget figures. Antosh said the increases need not all come from Medicaid funding but draw on a variety of other public and private sources.

CPNRI, meanwhile, offered estimates for system-wide reform that would not only increase wages but provide for more labor-intensive supports in the community in keeping with the requirements of the consent decree. The organization’s report said that at a direct care rate of $17.50 an hour, the more labor-intensive option would cost between $112.9 and $158.9 million, depending on the number of hours provided and other variables, including the level of independence of each individual as perceived by the state’s assessment tool.

CPNRI’s report incorporated work completed earlier this year by BHDDH consultants, as well as earlier projections done for the state by different consultants.

COVID-19 Exacerbates Inequities

The pandemic has highlighted the inadequacy of the poverty-level pay of direct care workers in the private sector. The average wage of $13.18 an hour falls below many entry-level jobs in retail, delivery, warehouse, restaurant and janitorial fields, according to the recent report from CPNRI.

That rate is also nearly $5 less than the $18 minimum hourly rate the state pays its own employees to do the same work, running a small parallel system of group homes for about 125 adults with developmental disabilities.

The years-long difficulties faced by providers in recruiting staff have reached critical proportions during the COVID-19 pandemic, leaving many individuals without services and crippling the agencies’ ability to generate income.

The crisis has been nine years in the making.

In 2011, the General Assembly devalued the private provider system when it adopted a new reimbursement model and budget cuts that were justified with an executive branch memo that simply said providers could deliver the same services with less money.

The $26- million budget cut resulted in layoffs and slashed wages. Entry-level positions for caregivers, once the starting point of a career ladder for caregivers who did not necessarily have college degrees, became minimum-wage, dead-end jobs.

At the time, the Department of Behavioral Healthcare, Developmental Disabilities (BHDDH) ignored the recommendation of an outside consultant who said direct care workers should receive a minimum of $15 an hour within a year’s time.

The state pleaded poverty in the aftermath of the financial crash of 2008 and 2009, but by 2011, most other states were either holding steady on previous cuts or beginning to reverse reductions in human service spending, including those for people with developmental disabilities.

The austerity move accompanied a new reimbursement system billed as “Project Sustainability,” intended to equitably distribute available funds to eligible adults with developmental disabilities. The reimbursement model incentivized congregate care in sheltered workshops and day care centers – the least costly form of supervision. Subsequently, the DOJ found that an over-reliance on congregate care violated the Integration Mandate of the Americans With Disabilities Act. That finding led to the consent decree.

In a recent report, CPNRI said that COVID -19 has thrust a system developed and funded for congregate care into one that must deliver personalized services to mitigate infection among a vulnerable population.

Long-term effects of neglect on the system prevent providers from being “agile and responsive to meet the demand and needs of the community,” said the report. For example, the reimbursement model assumes that 40 percent of services will be delivered in center-based care, which is prohibited by public health concerns.

Read the court monitor’s report here.

Read the CPNRI report, “System in Crisis” here.

RI Legislation Aims For Greater Accuracy And Transparency In Budgeting BHDDH, DCYF Costs

By Gina Macris

Companion bills in the General Assembly would require cost estimates for services to adults with developmental disabilities and children in state custody to become part of Rhode Island’s semi-annual Caseload Estimating Conference, a key budgeting guide. 

The bills, sponsored by Sen. Louis DiPalma, D-Middletown; and Rep. Teresa A. Tanzi, D-Narragansett and South Kingstown; specify that the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) and the Department of Children, Youth, and Families. (DCYF) would submit all their service costs, funded through Medicaid, to the Caseload Estimating Conference. 

Both BHDDH and DCYF have been plagued by chronic deficits. At BHDDH, a 2014 federal consent decree enforcing the 1999 Olmstead decision of the U.S. Supreme Court is putting additional demands on the developmental disabilities budget.

The executive branch prepares BHDDH budgets on the basis of “target” figures set by the Office of Management and Budget. In the past, BHDDH officials have said that the targets are not enough to cover actual service costs. This year, Governor Gina Raimondo accepted BHDDH figures in submitting her budget proposal to the General Assembly.

In a statement, DiPalma said, “The legislation is about honest and transparent budgeting. We need an accurate accounting of how many individuals we are serving in these vital programs, so that our budget reflects the associated costs, or makes program adjustments, or both.” 

He said about 3,000 children and teenagers are in DCYF care and roughly 4,000 adults with developmental disabilities depend on services from BHDDH.

Tanzi said, “Accurate caseloads will ensure the General Assembly is able to fully understand and appreciate the budgetary requirements of the agency to meet their obligations to our state’s vulnerable children and families. This legislation is about caring for our most vulnerable citizens but doing so in the most responsible way for the taxpayers.”

Medicaid accounts for about 31 percent of the state’s budget, according to the House Fiscal Office. That is roughly $3 billion in expenses annually, with each state dollar matched by slightly more than one federal dollar. Of all Medicaid funds, BHDDH spends 12.3 percent of and DCYF accounts for 1.4 percent.

In addition to adding BHDDH and DCYF to the Caseload Estimating Conference, DiPalma’s and Tanzi’s bills spell out the managed care reporting requirements of EOHHS in greater detail.

Current law allows agencies other than DHS and EOHHS to participate in the Caseload Estimating Conference but does not require them to contribute data.  It is not clear why DCYF and BHDDH have not been included in the Caseload Estimating Conference in the past.

The Caseload Estimating Conference runs back-to-back with the Revenue Estimating Conference in November and May. There are three principals; the House and Senate fiscal advisors and the state budget officer, who reach agreement through consensus on the latest estimates for revenue and for expenses in the human services, including Medicaid and a general public assistance program of about $1.5 million.

The governor relies, in part, on the November conference report to prepare the budget that is submitted to the General Assembly in January. The House and Senate use the results of the May conference as a basis for finalizing budget negotiations. 

The bills: S 0266 and H 5841