Section I, Part A – Project Introduction

Introduction to the Texas MFP Demonstration

Texas was one of the first of four states to have a comprehensive working plan in response to the Supreme Court’s Olmstead decision (June 1999). Then Governor George W. Bush issued an immediate response to the Olmstead decision with Executive Order (GWB-99, September 1999) which began Texas’ Promoting Independence Initiative (Initiative). The Executive Order mandated a high-level report that analyzed Texas’ long term services and supports system and required that policy and financing recommendations be made to the Governor and the Texas legislature in 2001, in order to be in compliance with the Olmstead decision.

The 77th Texas Legislature (2001) codified the report’s recommendations in Texas law through Senate Bills (SB) 367 and 368; the report, itself, became Texas’ original Promoting Independence Plan (Plan). This first Plan had approximately one hundred recommendations impacting all individuals who are aging and/or with a disability (physical, intellectual, developmental, behavioral) across Texas’ health and human services system.

Every two years prior to Texas’ legislative session (biennial), the human services system submits a revised Plan based on new recommendations from a stakeholders’ oversight committee (the Promoting Independence Advisory Committee [Committee] – which meets quarterly). There have been three revisions to the original plan which now encompasses more than a hundred initiatives for change. The Plan has and continues to impact the state development of its long term services and supports policy to provide individual choice and self-determination.

As part of the original Initiative and legislative action by 77th Texas Legislative Session (2001), two of the more major policy initiatives began, which have had lasting impact on state and national policy: (1) “Money Follows the Person” for individuals residing in nursing facilities (NF); and (2) the Promoting Independence priority populations for individuals with intellectual and developmental disabilities (IDD) residing in large (fourteen-plus bed) community Intermediate Care Facilities for Persons with Mental Retardation (ICFs/MR) and state mental retardation facilities (state supported living centers).

These accomplishments were the result of strong advocacy from consumers and advocate organizations, informed providers, and strong governmental leadership. This coalition continues in its efforts to meet goals of the state’s Promoting Independence Plan while the Promoting Independence Advisory Committee aggressively provides its advisory function.

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Money Follows the Person

Texas is one of the originators of the “Money Follows the Person” (MFP) financing policy and as of June 30, 2007 has transitioned 13,337 individuals from nursing facilities to community-based services. Texas’ MFP policy began on September 1, 2001 as a result of a rider to then-Texas Department of Human Services’ appropriations (DHS – this part of DHS is now part of the Texas Department of Aging and Disability Services). This rider allowed Medicaid-certified individuals who reside in a NF to access 1915 (c) waiver and other community services without being placed on an interest (waiting) list. Subsequent legislatures continued the rider and the 79th Texas Legislature (2005) codified the policy into law with House Bill 1867. Since the beginning of the policy, the state has understood the importance of a supportive infrastructure to assist individuals in their personal transition. These support programs and policies include:
  • Transition to Life in the Community (TLC) funds: general revenue funds to assist an individual to pay for household and moving expenses that are not available under Medicaid.
  • Transition Assistance Services (TAS): a $2500 one-time capped allowable expense under the adult nursing facility 1915 (c) service array to assist an individual in paying housing down payments and the purchasing of household items in order to establish a community residence.
  • Community Transition Teams (Teams): these are public-private regional community resource coordinating groups who work with individual and systematic barriers to community relocation; these Teams were established with the assistance of a 2002 Real Choice Grant.
  • Relocation Contractors: this is a statewide network of contracted organizations who hire relocation specialists to help identify individuals in NFs who want to relocate back into their communities. Relocation specialists provide outreach, identification, facilitation, and housing navigation services to assist in the relocation, as well as post-transition follow-up activities.
  • Housing Voucher Program: this program is administered through Texas’ housing financing agency (Texas Department of Housing and Community Affairs) to provide Section 8 Project Access Vouchers for individuals leaving NFs.

As June 30, 2007, 13,337 individuals have successfully transitioned from NFs accessing 1915 (c) waiver services – the actual number of NF residents has decreased from 61,678 in 2001 to a projected 56,832 in Fiscal Year 2008.

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Promoting Independence Priority Populations

The original Promoting Independence Plan (2001) mandates that individuals in state supported living centers or in medium (nine to thirteen) large (fourteen-plus) community ICFs/MR have expedited access to Texas’ Home and Community-based Services (HCS) 1915(c) waiver. Individuals residing in a state supported living center may access HCS waiver services within six months of referral, while individuals residing in large community ICFs/MR may access community-based services within twelve months. Since these programs began, 1,031 individuals have moved from the state supported living centers and another 796 individuals have moved from large community ICFs/MR into HCS.

Individuals in large community ICFs/MR and state supported living centers must go through an annual “Community Living Options” (CLO) process to inform those residents of their rights and community options. This extensive process engages the individual and/or their legal guardian in a face-to-face meeting with facility staff to review their current status, and to help identify those individuals who want an alternative living arrangement to the institutional setting. The 80th Texas Legislature (2007) mandated that the CLO process be administered to state supported living center residents by the local Mental Retardation Authority (see Glossary).

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Key Demonstration Objectives

MFP is not a new concept for Texas. Our extensive history with nursing facility MFP and relocation for individuals with IDD gives Texas both the knowledge and the infrastructure to successfully implement this Operational Protocol and to enhance the state’s current efforts. Texas has six years of experience working with individuals in institutional settings, providing them with the information and assistance they need in order to make an informed choice on where they want to receive their long term services and supports. Texas has demonstrated its willingness to rebalance its system and has successfully pioneered many of the national efforts in community transition.

There have been many lessons learned during the past six years, which have provided the data on which to base this OP. The state has identified many of the barriers to a successful relocation. Texas will use the MFP Demonstration to respond to those identified barriers and to provide the necessary additional supports; those new initiatives include:

  • Community behavioral health cognitive Adaptation training and substance abuse services
  • Overnight support services
  • Post-transitional services; and
  • Voluntary closure of nine-plus bed community ICFs/MR.

As significantly, Texas understands the importance of a robust regulatory and quality management process. The state has implemented policies and procedures to ensure a safe environment so that individuals will receive quality community services. The state also understands, however, that an individual or their guardian may want to take certain risks in order for that individual to relocate back to the community. Texas strongly supports the principles of self-determination and that an individual with capacity or their guardian should have the final decision in the delivery of their services

The following are Texas’ statements of fact that it will meet the four key demonstration objectives as outlined in statute. The statements of fact are categorized under three headings: Ongoing Public Policy; Recent Legislative/Policy Action; and Demonstration Activity(ies).

The state must address the four key demonstration objectives as outlined in statute in their project introduction. These objectives are to:

  1. Increase the use of home and community-based, rather than institutional, long-term care services;

Increase in Use of Home and Community-Based Services

Texas has and will increase its use of home and community-based services by:

Ongoing Public Policy

  • Assisting relocation contractors to help identify individuals who want to relocate and facilitate that transition (see above).
  • Proposing the continuation of the budgetary line item within the Texas Department of Aging and Disabilities’ appropriation for MFP.
  • Allocating 1915(c) waiver slots for individuals with intellectual and developmental disabilities who want to leave the state supported living center system or large (fourteen-plus bed) community ICFs/MR.
  • Dedicating line items in both the DADS’ and Health and Human Services Commission’s appropriations to help support community services and relocation activities ($2.6 million).
  • Contracting activities to help children relocate back to the community by supporting their biological parents or if that is not possible, establishing alternative families to assist the biological parents (Family-based Alternative program).
  • Mandating through Senate Bill 368 (77th Legislature, 2001) the process of permanency planning for children in institutional settings to establish plans for relocation to the community and for subsequent six month reviews.
  • Passing flexible nursing delegation rules.
  • Maintaining the nation’s only 1929(b) program, as part of its state plan entitlement services, which provides individuals with up to 300% of SSI with attendant services.

Recent Legislative/Policy Action

  • Expanding the MFP policy to allow children (0-21) with intellectual and developmental disabilities who are in NFs to access a HCS 1915(c) waiver.
  • Increasing the individual cost cap for (c) waiver programs from 100 to 200 percent of the NF cost, and from 80 to 200 percent of the ICF/MR cost.
  • Dedicating HCS 1915(c) waiver slots for children (0-21) who are aging out of Texas’ Foster Care system.
  • Dedicating NF 1915(c) waiver slots for children (0-21) who are aging out of Texas’ EPSDT program.
  • Implementing new legislation that will improve Texas’ outreach and information process to individuals within its state supported living center system to inform them of their community options (this is known as “Community Living Options,” an annual process, which will be conducted by the Texas’ Mental Retardation Authorities).
  • Expanding the long-term services and supports managed care system to include five services areas; individuals who meet the Supplemental Security Income (SSI) eligibility criteria will have access to 1915(c) nursing facility waiver services without having to be on an interest (waiting) list.
  • Funding a special nursing rate to assist individuals with ventilator needs to be able to relocate/remain in the community.

Demonstration Activities

  • Introducing two new Demonstration services within the MFP Demonstration to provide additional community supports for individuals with behavioral health needs and for those who require overnight assistance.
  • Including as part of the MFP Demonstration the activity of working with providers of nine-plus bed community ICFs/MR who want to close their facilities, take their Medicaid-certified beds off-line, and possibly become HCS waiver providers, which will offer those residents community options.
  • Piloting, as part of the Demonstration, an Overnight Support Service, which will allow more individuals with complex needs and without informal supports, to relocate back into the community to receive long term services and supports.
  1. Eliminate barriers or mechanisms, whether in the State law, the State Medicaid plan, the State budget, or otherwise, that prevent or restrict the flexible use of Medicaid funds to enable Medicaid-eligible individuals to receive support for appropriate and necessary long-term services in the settings of their choice;

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Elimination of Barriers and Flexible Use of Medicaid Funds

The Texas Legislature has done the following to eliminate barriers that prevent or restrict the flexible use of Medicaid funds.

Ongoing Public Policy

  • Codified Texas’ response to the Olmstead decision (Senate Bill 367, 77th Legislature, 2001) and acceptance of the Promoting Independence Plan, which provides among its many initiatives: (1) expedited access to HCS 1915 (c) waiver slots for individuals with IDD (and provided additional funding for those slots), and (2) requires intensive community mental health services for individuals with three more admissions within a six month period into a state mental health facility in order to avoid further hospitalization.
  • Codified (House Bill [HB] 1867, 79th Legislature, 2005) the MFP policy and established a dedicated line item in the DADS’ appropriations for MFP funding. The law states that all individuals who meet the eligibility criteria may relocate back into the community without having to be placed on a 1915 (c) waiver interest (waiting) list.

Recent Legislative/Policy Action

  • Attached the following Riders to DADS’ appropriation (80th Legislature, 2007):
    • Rider 37 dedicates 120 HCS 1915(c) waiver slots for Fiscal Years 2008-2009 for children aging out of foster care and 180 slots for individuals leaving fourteen-plus bed community ICFs/MR;
    • Rider 41 will provide HCS 1915(c) waiver slots for children (0-21) who reside in NFs;
    • Rider 43 will provide IDD 1915 (c) waiver slots for fifty children residing in eight-bed or less ICFs/MR; and
    • Rider 45 will increase individual (adult) cost caps for NF 1915 (c) waiver services from 100 percent of the NF costs to 200 percent and for individuals with IDD who are accessing the HCS 1915(c) waiver from 80 percent of the ICF/MR cost to 200 percent.

Demonstration Activity

  • Attached Rider 7 to the Special Provisions of the Health and Human Services Commission’s (state Medicaid agency) appropriation which will allow enhanced matching dollars from the MFP Demonstration to be utilized to enhance community services and supports.
  1. Increase the ability of the State Medicaid program to assure continued provision of home and community-based long-term care services to eligible individuals who choose to transition from an institution to a community setting; and

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Continued Provision of Community-Based Services

The following actions increase the ability of the state Medicaid program to assure continued provision of community-based services.

Ongoing Public Policy

  • Submittal of the biennial Promoting Independence Plan (Plan) to the Governor and the Texas Legislature, which states the need for reduction and ultimate elimination of Texas’ community interest lists in addition to scores of other recommendations to enhance the community-based long term services and supports system.
  • Scheduled quarterly meetings of the Promoting Independence Advisory Committee (PIAC), which oversees the hundreds of initiatives within the Plan, makes additional recommendations for new initiatives, and provides overall oversight on the state’s compliance to the Olmstead decision. Codification of the MFP policy into statute (see above discussion on HB 1867).
  • Settlement of a lawsuit that requires the Health and Human Services Commission to request in its LAR a twenty percent reduction of the community interest (waiting) lists for the next two biennia (Fiscal Years 2010-2011 and 2012-2013).
  • Codification of the MFP policy into statute (79th Legislature, 2005 – see above discussion on House Bill 1867).

Recent Legislative/Policy Action

  • Increased coverage within the long term services and supports managed care system which allows all individuals who are aging and/or with physical disabilities on SSI, and who meet the eligibility criteria, to receive 1915(c) waiver services.
  • Inclusion of additional HCS 1915 (c) slots to address enhanced efforts to provide community options for individuals who want to leave the state supported living center system.

Demonstration Activity

  • Inclusion of Rider 7 to the Special Provisions of the Health and Human Services Commission’s (state Medicaid agency) appropriation which will allow enhanced matching dollars from the MFP Demonstration to be utilized to enhance community services and supports.
  • Inclusion of all individuals in Demonstration as part of the baseline information that is utilized in the development of the agency’s Legislative Appropriation Request (LAR) which is used in building the state’s two-year budget.
  • Inclusion within this Operational Protocol that the state assures it will continue services to individuals who transition.
  • Inclusion of an assurance within this Operational Protocol that the state will evaluate the success of the behavioral health and the overnight support services demonstration services to determine their inclusion in current state 1915(c) waivers for statewide services.
  1. Ensure that a strategy and procedures are in place to provide quality assurance for eligible individuals receiving Medicaid home and community-based long term care services and to provide for continuous quality improvement in such services.

Quality Strategies and Continuous Quality Improvement (Ongoing Public Policy)

Texas has always had a strong commitment to quality for all its recipients of services. This commitment was enhanced through a three-year Real Choice Systems Change Grant awarded by CMS in 2003 to improve quality in community-based programs. Two of the major accomplishments of the grant were the development of a systematic approach to gathering information on the experiences of individuals receiving services in the community and the first phase of the development of a Quality Assurance and Improvement (QAI) Data Mart.

Annual Face-to-Face Surveys

Each year, Texas conducts face-to-face consumer surveys to obtain information directly from the individuals receiving community-based services, and measure achievement of their goals and aspirations. Depending upon the characteristics of the individuals being surveyed, two different survey instruments are utilized.

Texas is a member of the National Core Indicators (NCI) project developed by the Human Services Research Institute. The NCI project is designed to assist member states (22 states) with developing performance and outcome measurement strategies for their programs. The project provides a nationally recognized survey instrument, the NCI Consumer Survey, which was designed specifically for people with intellectual and developmental disabilities. The survey contains multiple questions to calculate specific indicators that are grouped by four different domains: consumer outcomes, system performance, health, welfare and rights, and self-determination.

The second survey instrument Texas uses is the Participant Experience Survey (PES) developed by MEDSTAT Group, Inc. for CMS. The PES was designed to collect information directly from elderly and non-elderly adults with physical disabilities and divides questions into five domains: access to care, choice and control, respect/dignity, community integration/inclusion, and self-determination.

The results of these surveys are shared with internal and external stakeholders to identify experiences of the individuals receiving services, to develop intervention strategies and, to assist in program improvement activities.

Continuous Quality Management

Texas also employs the process of continuous quality management (CQM) to determine whether its programs operate in accordance with CMS’ approved design and meet statutory and regulatory assurances and requirements. CQM is one of the mechanisms to ensure individuals achieve desired outcomes, identify opportunities for program and service improvement, and ensure that public funds are spent efficiently and for the benefit of the people of Texas. The major activities are conducted by the following divisions:

  • Regulatory Services (RS) Division. This division is responsible for the licensure and/or certification of nursing facilities, intermediate care facilities for persons with mental retardation, assisted living, adult day care facilities, and home health and hospice agencies. Surveyors monitor the performance of these providers by conducting routine surveys, inspections and complaint/incident investigations and require a corrective action plan if state violations and federal deficiencies are found. Follow-up surveys and inspections are conducted to ensure that the provider has effectively implemented any required corrective action plan. All surveys and inspections are unannounced and include an observation of the care of the individual.
  • Provider Services (PS) Division. This division is responsible for conducting on-site contract monitoring visits to ensure providers are in compliance with program rules and to verify service delivery and payment. Provider complaint and payment histories are collected from a DADS database and reviewed prior to conducting the monitoring visits.
  • Consumer Rights and Service (CRS) Unit. This unit maintains a complaint data base and receives complaints from applicants, individuals enrolled in Medicaid programs, or their families and representatives. Staff from the CRS unit will investigate the complaint and attempt resolution of it unless the complaint involves abuse, neglect, or exploitation of an individual receiving services. Complaints involving allegations of abuse, neglect, or exploitation are referred immediately to the Texas Department of Family and Protective Services (DFPS), the agency with statutory responsibility for investigation of such allegations. Resolution of complaints not referred to DFPS are tracked and recorded in the CRS Complaint Data Base.
  • Adult Protective Services (APS). APS is a division of Texas Department of Family and Protective Services within the Texas Health and Human Services Enterprise. APS is responsible for investigating allegations of abuse, neglect, and exploitation of adults who are elderly or those with disabilities, including cases in which a provider is alleged to have abused, neglected or exploited a participant. APS assigns one of four priority levels to complaints at the time of the complaint intake. APS complaint investigators must contact the alleged victim by phone within 24 hours of intake. The investigator may change the priority level as a result of the phone contact. APS must make the initial face-to-face contact with the alleged victim based on the priority level.

DADS is responsible for abuse, exploitation, and exploitation investigations of persons who are elderly and persons with disabilities or other residents living in facilities licensed by DADS.

Demonstration Activities

QAI Data Mart. Texas is advancing its work on its QAI Data Mart which will be a primary source of data for filing MFP Demonstration reports. The QAI Data Mart will compile data currently collected in multiple automated systems. Consultants have designed the data mart to produce standardized reports, as well as provide capability for ad hoc reporting. The areas covered by the reports will include: participant demographics; services utilization; enrollments; levels of care; plans of care; consumer-directed options, critical incidents; abuse, neglect, and exploitation incidents; long-term services and support (LTSS) provider compliance and oversight; transfers; discharges; complaints, and recoupments. The system will have the capability to provide management reports at the participant level.

At least quarterly, Texas will compile reports regarding performance of the MFP Demonstration and provide them to program staff for review and appropriate action. Additionally, these reports will be presented to the MFP Demonstration Advisory Committee for their review and comment on the status of the MFP demonstration and program improvement activities.

  • Quality of Life surveys: Texas will comply with the Demonstration’s Quality of Life surveys as prescribed by CMS.

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Updated: April 26, 2018