The House and the Senate each approved their versions of the 2018-2019 biennial budget. At six percent below 2016-2017 spending levels adjusted for population growth and inflation, neither budget adequately addresses the health and human services needs of Texans with disabilities.
Each chamber used different methods to get to within a billion of each other. The House chose to dip into the Rainy Day Fund, using $2.5 billion of the $12 billion expected to be available by the end of the biennium to finish paying for the 2016-2017 commitments via the supplemental appropriations bill, HB 2. The Senate includes more funding for Medicaid in its 2018-2019 version of the budget.
Very few disability related exceptional items were fully adopted into Article II, the health and human services section of the Texas budget. The bulk of the funding requests were moved to Article XI which is also known as the “wish list” category. For the first time in a decade, neither chamber considered additional funding for interest list reduction. Attendant wages also were not considered by the 85th Texas Legislature. Therefore, interest lists will continue to grow beyond the current 132,000 people waiting and the attendant wage floor will remain $8 per hour.
HHSC proposed the elimination of Texas’ nationally renowned relocation specialist function which has helped to transition 4,255 individuals from nursing facilities to the community during fiscal years 2013-2016. Despite substantial advocate opposition, evidence of provider expertise, and the significant return on investment associated with the function, HHSC will not seek the $5 million used by relocation contractors for outreach, identification, facilitation, and housing navigation, functions not typically included in the Medicaid state plan. HHSC will transfer this function to the Managed Care Organizations (MCOs) to contract with providers for this function. What is not known is whether needed funds will be available, what services will be provided, and what level of oversight and accountability HHSC will provide.
EARLY CHILDHOOD INTERVENTION (ECI)
HHSC reduced its request from $44 million to only the available $19.8 million in federal Individuals with Disabilities Education Act (IDEA) PART C funds. Federal IDEA PART C funding may only be spent on the ECI program. However, the current debate focuses on whether the program needs the funds.
The Senate did not include additional ECI funds in its budget. The House adopted an amendment instructing that if HHSC confirms the availability of the $19.8 in IDEA Part C funds from this fiscal year exists they may work with the Legislature to ensure the funds are properly appropriated. A similar provision was included in the previous budget. Funds for this program are currently not being released and providers are withdrawing from the ECI program.
MAINTAIN COMMUNITY SERVICES
In anticipation of the lean budget outlook, in November 2016, HHSC quietly froze interest list reduction releases approved by the 84th Texas Legislature. Both chambers report their budgets fully fund services for the waiver participants anticipated to be enrolled in August 2017. The House’s funding levels would support 28,091 HCS waiver participants and the Senate’s funding levels would support 25,980 HCS waiver participants.
HHSC’s February projection anticipates that 26,853 people will be receiving HCS services in August, only 124 more than the 26,729 people currently enrolled in the HCS waiver program.
|Waivers of Interest||HHSC Projection|
|Senate Less House|
Neither chamber fully funds Promoting Independence. Promoting Independence makes community waiver services available to people in institutions and those at risk of going into institutions. The House put the full Promoting Independence request in Article XI (the “wish list”). The Senate provides funds for HCS services for 276 children associated with the Child Protective Services (CPS) and puts half of the remainder of the Promoting Independence request on the wish list. The Senate decision document refers to “crisis stabilization” services for 200 people. It is unclear whether crisis stabilization services are considered temporary or whether these are the typical HCS services for people at imminent risk of State Supported Living Center (SSLC) admission.
Without investments in Promoting Independence, relocation services, or interest list reductions, it is not clear how Texas will meet its obligations under Olmstead which entitles persons to receive services in the least restrictive setting according to their needs – usually community based waiver services.
|Promoting Independence Groups||# of people||Senate Article II||Senate Article XI||House Article II||House Article XI|
|HCS for People Moving from SSLCs||400||-||200||-||400|
|HCS for People Moving from Large ICFs||100||-||50||-||100|
|HCS for Youth Aging out of Foster Care (CPS)||236||236||-||-||236|
|HCS for Persons at Imminent Risk of Entering an ICF||400||-||200||-||400|
|HCS for People with IDD Moving from State Hospitals||120||-||60||-||120|
|HCS for Children Moving from a general residence operations (GRO) facility (CPS)||40||40||-||-||40|
|HCS for People with IDD moving from nursing facilities||700||-||350||-||700|
|HCS for People with IDD at risk of entering a nursing facility||600||-||300||-||600|
- Home and Community-based Services (HCS) and Texas Home Living (TxHmL) – In January, HHSC announced its intent to apply a 21% rate reduction to the Community First Choice (CFC) attendant and habilitation services provided in the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) programs. This reduction is not part of the current budget process, but can be implemented by HHSC to meet the last legislature’s instructions for cost containment goals. Individuals and families warn that such drastic cuts threaten the stability of attendant care teams. Without community based attendants, some people will be forced to move to more restrictive, more expensive settings to receive needed support.
- Pediatric Therapy Rate Reductions – The Senate’s version of the budget does not include funding to restore the therapy rate reductions adopted by the 84th Texas Legislature. Therapies included in the rate and policy changes included physical, occupational, and speech therapies for children. Despite substantial testimony reporting diminished access to care and waiting lists for assessments, Senate budget writers regard this as a “media” issue rather than an access issue. The House’s version of the budget includes funds to restore approximately 75% of the pediatric acute therapy rate reductions. Regardless of legislative action, HHSC is proposing additional therapy rate methodology changes that, if implemented, would result in reductions of about 30% for services provided by therapy assistants which may disproportionately affect Spanish speaking therapy recipients.
INTERMEDIATE CARE FACILITY (ICF) CONVERSION
The Senate’s version of the budget would permit small ICFs with four or fewer individuals living in the home, who voluntarily relinquish their ICF bed, to convert to HCS waiver placements. The number of waiver placements would increase the total number of HCS waiver participants, and affected ICF beds would be decertified. The House’s version of the budget would require a study only.
STATE SUPPORTED LIVING CENTERS
Both versions of the budget anticipate 400 fewer SSLC residents in 2018-2019 and provide less funding for SSLCs than the prior biennium. The Senate provides about $100 million less than the House. As a reminder, neither budget fully funds Promoting Independence, the services that would be used by the 400 SSLC residents assumed transition from the institutions to the community.
HOME AND COMMUNITY BASED SERVICES SETTINGS RULE COMPLIANCE
(Day Hab/Meaningful Day):
The new Centers for Medicare and Medicaid Services (CMS) administrators signaled that states would receive additional time to achieve compliance with the HCBS Settings Rule. As the result, both chambers chose not to include funding to bring day habilitation programs into compliance with the HCBS Settings Rule. Even without the HCBS Settings Rule requirements, segregated day habilitation programs require significant improvement to ensure health and safety and ensure people have meaningful control over their day. A session without this funding means that critical improvements will be delayed another two years.
SUNSET COSTS, SB208 (2015)
This would fund anticipated – but unfunded – costs associated with the 2015 decision to transfer Vocational Rehabilitation (VR) to the Texas Workforce Commission (TWC) including funding to maintain field support staff for Comprehensive Rehabilitation Services (CRS), Children’s Blindness Services, and Independent Living Services (ILS). Services have already been scaled back.
|Chamber||Request||Article II||Article XI|
|Senate||$9.2M GR||$4.1M GR||$5M GR|
|House||$9.2M GR||-||$9.1M GR|
Cost containment is once again featured prominently in the Texas budget. Cost containment initiatives include directives to HHSC to achieve savings by expanding prior authorization, increasing utilization review, implementing co-payments and potentially reducing rates for durable medical equipment. The House’s budget further directs HHSC to renegotiate its current Medicaid contracts to achieve an additional $450 million in savings. The House also assumes $1 billion in savings associated with and HHSC directive to seek additional federal flexibility in the overall administration of Medicaid. Although the House budget specifies that federal flexibility is to be achieved: without changing eligibility levels; reducing benefits; or adjusting amount, scope or duration of services, there are a variety proposals moving through the legislative process predicated on block granting Medicaid to include changes to eligibility or optional services.
Lieutenant Governor Dan Patrick and Speaker Joe Straus appointed a conference committee, a small group of senators and representatives, to negotiate the final details of the 2018-2019 General Appropriation Act.
- Representing the Senate: Senators Jane Nelson, Juan “Chuy” Hinojosa, Joan Huffman, Lois Kolkhorst, and Charles Schwertner.
- Representing the House: Representatives John Zerwas, Oscar Longoria, Sarah Davis, Trent Ashby, and Larry Gonzales.
The conference committee will primarily focus on items in the budget where there is no agreement, however, the conference committee could agree to change items in other areas of the state budget as well. The conference committee phase of budget negotiations is the least transparent part of the budget process. Few, if any, hearings will be accessible to the public.