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F I S C A L I M P A C T R E P O R T

SPONSOR Ortiz y Pino

DATE TYPED 2-10-05

HB

SHORT TITLE Services for Medically Fragile Children

SB 363

ANALYST Collard

APPROPRIATION

Appropriation Contained Estimated Additional Impact Recurring

or Non-Rec

Fund

Affected

FY05

FY06

FY05

FY06

$300.0

Recurring General Fund

(Parenthesis ( ) Indicate Expenditure Decreases)

Duplicates HB 82

SOURCES OF INFORMATION

LFC Files

Responses Received From

Department of Health (DOH)

Health Policy Commission (HPC)

Human Services Department (HSD)

SUMMARY

Synopsis of Bill

Senate Bill 363 appropriates $300 thousand from the general fund to the Department of Health

for the purpose of maintaining case management services for medically fragile children in FY05

and FY06. Any unexpended or unencumbered balance at the end of FY06 will revert to the gen-

eral fund. This bill contains an emergency clause.

Significant Issues

DOH notes the Long-Term Care Services Program currently administrators the Medicaid Medi-

cally Fragile Waiver program that serves individuals from birth to death who meet the medical

and financial criteria set forth by Medicaid. A part of the program service is to contract with case

management services to coordinate healthcare related services for the medically fragile waiver

clients statewide who have been approved for services. Currently, there are statewide case man-

agement services available.

Senate Bill 363 -- Page 2

The existing rate of reimbursement for case management services is based on a rate validation

study that was conducted beginning in September 1999 that resulted in reimbursement rate in-

creases by the program for the case management services for medically fragile waiver clients.

The department also notes the Long-Term Care Services Program will be conducting a rate study

specifically for case management services in spring 2005. DOH believes that the covered reim-

bursement rate is appropriate but is committed to further evaluation of the current medically

fragile waiver case management rate and service delivery model.

FISCAL IMPLICATIONS

The appropriation of $300 thousand contained in this bill is a recurring expense to the general

fund. Any unexpended or unencumbered balance remaining at the end of FY06 shall revert to the

general fund.

HSD notes, if the services are rendered to Medicaid eligible clients, Medicaid expenditures could

increase by as much as $1.1 million of which $770 thousand would be federal matching funds.

ADMINISTRATIVE IMPLICATIONS

DOH indicates staff time would be required to oversee the use of $300 thousand appropriated to

assure the appropriation is used to serve medically fragile children.

DUPLICATION

Senate Bill 363 duplicates House Bill 82.

OTHER SUBSTANTIVE ISSUES

DOH indicates the department is required to maintain case management services for the Medi-

cally Fragile Waiver recipients by the Center for Medicare and Medicaid Services (CMS) as a

Home and Community Based Waiver Service (HCBWS).

Reimbursement for Medically Fragile Waiver case management is $394 per month. Currently,

152 individuals receive Medically Fragile Waiver services. DOH intends to serve additional in-

dividuals who meet criteria for services with the goal of serving up to 200 individuals. The de-

partment indicates, if the $300 thousand were appropriated, and this funding were used to sup-

plement the current case management reimbursement rate for 200 medically fragile waiver re-

cipients, the rate would be $519 per individual per month. This is calculated as follows: $300

thousand divided by 200 individuals equals $1,500. This, divided by 12 months, equals $125.

Therefore, the current rate of $394 would be added to the increased funding of $125 to equal

$519 per month per individual for Medically Fragile Waiver case management services.

DOH has committed to undertake a rate study this spring. The results of this rate study will assist

in determining if the current rate is appropriate or not.

HPC indicates the importance of case management for medically fragile children and all medi-

cally fragile individuals is to help keep them living in their own home as long as possible, delay-

ing hospitalization or institutionalized care. Case managers use a family centered approach to

Senate Bill 363 -- Page 3

care, and act as advocates, resource persons, facilitators, and paperwork coordinators for fami-

lies. Case managers also support parents as team leaders who address the day-to-day care of

their child and services in the community, as well provide support to families in their decision to

care for their medically fragile child in their home.

Case management is a service provided by trained professionals who assess needs and coordinate

service. Case managers meet with the individual and family members to conduct a thorough as-

sessment of the individual’s health and safety needs. Through this assessment, the case manager

can determine the strengths, weaknesses and specific needs of that individual. The case manager

can then pass along information on programs or services that may be available to the person to

help keep them safely in their own homes. Case managers also develop individualized care

plans, which detail the type of services needed, the frequency, and the payer source for each ser-

vice. Government programs, private insurance, family, friends, and public services are included

in the planning stages in developing a plan of care.

WHAT WILL BE THE CONSEQUENCES OF NOT ENACTING THIS BILL.

DOH notes, if the bill is not enacted, the case management reimbursement rate will remain at

$394 per month at least until the rate study is completed. At that time, based on the results of the

rate study, the DOH and the Human Services Department will have to consider if a rate change is

warranted.

HPC indicates no additional funding for case management services may adversely affect the

health of the vulnerable population of medically fragile children and the public’s health and

safety concerns.

KBC/njw