Gauging the Use of HCBS Supports Waivers for People with Intellectual and Developmental Disabilities: Final Project Report

APPENDIX A. STATE-BY-STATE SUPPORTS WAIVER PROFILES

PDF Version (100 PDF pages)

TABLE OF CONTENTS

CONTENT OF STATE SUPPORTS WAIVER PROFILES

ALABAMA

COLORADO

CONNECTICUT

FLORIDA

INDIANA

LOUISIANA

MISSOURI

MONTANA

NEBRASKA

OHIO

OKLAHOMA

OREGON

PENNSYLVANIA

SOUTH DAKOTA

TENNESSEE

TEXAS

WASHINGTON

NOTES

CONTENT OF STATE SUPPORTS WAIVER PROFILES

The following profiles compile extensive information concerning supports waivers that are operated in 17 states. The profiles have been structured to capture uniform information across all the supports waivers in operation in 2006. In particular:

• Waivers in Operation. A listing of the approved waivers for people with intellectual and other developmental disabilities (I&DD) operated by the state: The waivers are listed by name along with the following information: type (i.e., comprehensive or support), Centers for Medicare & Medicaid Services (CMS) waiver number, the number of participants in 2005, start date and status (e.g., on-going, initial, pending CMS approval). The list includes the comprehensive waiver to which the supports waiver is linked. In a few cases, states operate other waivers for people with I&DD that are not listed, but these waivers are not linked directly to comprehensive waivers.

• Supports Waiver Features. This section contains basic descriptive information about each supports waiver, including:

  • The target population (who the waiver serves);

    Funding limits (the maximum dollar amount of waiver services that may be authorized for a waiver participant);

    Funding parameters or relevant rules that govern how funds are allocated under the funding limit;

    Exceptions (if any) to funding limit including how such exceptions are managed;

    Provisions regarding transition to the comprehensive waiver to illustrate how an individual may move from the supports to the comprehensive waiver;

    Whether the waiver includes features to promote self-direction. Waivers and state materials were reviewed for indicators to show that the waiver provides for individual budgets, permits participants to direct how these funds are spent, and/or supports participants in employing support workers.

• Supports Waiver Services. This section provides information on the services that the supports waiver offers. To facilitate cross-state/cross-waiver comparisons of the scope of waiver services, Human Services Research Institute (HSRI) defined 16 broad service categories to classify the services offered through the supports waivers. State waiver service definitions were reviewed and services were sorted into these predefined categories. These service categories are further described in the table on the following page. In each profile, it is shown whether or not the waiver offers each service type. If so, the particular service label applied by the state is also shown.

• Background Information on the Supports Waiver. This section offers background information on how and why the supports waiver was developed. This discussion identifies the unique state dynamics that may be in play that served as impetus for implementing a supports waiver. Common driving factors include: (a) holding down costs or make systems more cost efficient; (b) addressing increasing service demand (waiting list reduction); (c) developing service options to promote consumer-direction; and, (d) coming into compliance with CMS State Medicaid Director Letter #4.

• Current/Major Issues or Changes Underway. This section discusses factors that may have an impact on a state’s waiver strategy. This could include: (a) the impact of active court cases regarding wait-lists; (b) anticipated outcomes resulting from consultations with CMS staff regarding waiver administrative structure or operations; (c) changes to waivers that states are planning to make; and (d) changes in state budgets that have the potential of altering how a waiver is structured or run.

• Statistical Profile. This section provides information on comprehensive and support waivers regarding the number of participants served by waiver and associated costs. In most instances, the data depicts waiver utilization and expenditures during the period 2000-2006. In some instances, data were only available through 2005; in a few cases, states provided year out projections. Complementing graphics are also presented to illustrate changes over the period.

• Web-Accessible Resources/Documents Inventory. This section offers information about waivers that is available on the Internet or that was collected in print copy.

• State Contact Information. Information is offered to show the name of a key contact person and their address, phone number and email address.

ALABAMA

Background Information: Supports Waiver

The Living at Home (LAH) Waiver was first approved by CMS in 2002 but not implemented until 2003. The waiver was designed to provide low cost services and supports to individuals with mental retardation who live with their families or on their own and as a tool to reduce the state’s waiting list for services. The waiver provides both in-home and day supports as well as other ancillary services. The waiver stresses the use of person-centered planning methods in support of family/participant direction of services. Participants may select a community specialist to assist in the development and implementation of the person-centered plan. When community specialist furnishes on-going support, the frequency of case manager monitoring is reduced. State officials also report that the waiver is playing a role in its systems change initiative to eliminate the practice of “paying for the program” in Alabama (i.e., paying for slots in a particular program run by a private provider, rather than paying for the particular array of services and individual is determined to need). Community specialist services also have been added to the comprehensive waiver. The supports waiver uses a pre-authorized payment system to create a model that funds people, not programs. The state is implementing a new billing and data management system that will make the LAH Waiver much more usable by simplifying service authorization and billing.

The waiver has been slow to ramp up due to the lack of state funding. Recently, however, additional funds have been released to permit the program to be expanded. Alabama has been sued in federal court concerning the wait-listing of individuals for community services. Recently, a tentative settlement agreement was developed by the parties to eliminate the 1,400 person waiting list through a 3-year expansion of the LAH Waiver. However, this agreement was nixed by the Attorney General and the lawsuit continues to be litigated. Since openings are available in the comprehensive waiver, the state is able to shift individuals between the waivers as necessary. The state uses a criticality scale to determine placement on the waiting list, so that those with the most critical needs are the first to fill slots in the comprehensive waiver.

Alabama’s longer-standing comprehensive waiver provides a full-range of community services and supports. In recent years, the program has underwritten the costs of community placements from the state’s institutions as part of the settlement of the 33-year Wyatt v. Stickney lawsuit. At present, Alabama operates only one large public facility.

The next year, 2007, is a critical year in the waiver for developments that will help it become larger and viable. The developmental plan includes:

1. Implementing a revised billing and payment system that will put both the comprehensive and supports waiver on the same operational platform, that of funding people rather than programs. In this manner, applicants can be taken from the waiting list into whichever waiver meets their needs. Plans of care will be able to be changed on-line to meet a person’s needs, and plans will be monitored for timeliness, adequacy and full utilization through connection with paid claims history.

2. Implementing a comprehensive data management system that will connect all providers and all case managers to the Department of Mental Health and to the Medicaid Agency. All officials and staff whose function involves developing information about a person will be connected to the automated system. All information will be able to be aggregated and trended for analysis, outcomes and quality improvement. Applications and enrollments will be simplified and made faster, and enrolling providers and tracking their certification status will be automated.

3. Using the Supports Waiver to reach deep into the waiting list. This next year, funding has been requested to reach the next 600 people on the list.

Statistical Profile

Between 2000 and 2005, Alabama’s waiver enrollment increased by 23.3 percent, principally to support the community placement of individuals from the state’s large public facilities.

ALABAMA WAIVER ENROLLMENT

ALABAMA WAIVER EXPENDITURES ($M)

Between 2000 and 2005, total waiver expenditures more than doubled due principally to the expansion of the comprehensive services waiver.

ALABAMA EXPENDITURES PER PARTICIPANT

Document Inventory

• 2002 LAH Waiver Initial Waiver Application
• 2005 LAH Waiver 5 Year Renewal Application
• HCFA 372s: LAH 03-04, 372 LAH 04-05 and Comprehensive 00-01& 02-03 & 03-04

COLORADO

Background Information: Supported Living Services Waiver

Colorado was the first state to design and implement a “supports waiver.” In 1991, Colorado was one of eight states selected by the federal Health Care Financing Administration (HCFA, now CMS) to offer Community Supported Living Arrangements (CSLA) services. When the CSLA authority expired in 1995, Colorado decided to continue furnishing these services through a separate HCBS waiver (Supported Living Services (SLS) Waiver) that would operate side-by-side with the longer standing HCB-DD Waiver.

In the late 1990s, Colorado engaged in the Systems Change Project. An outcome of this project was to revamp both waivers to divide state payments for waiver services between comprehensive and supports services. The project also envisioned the state’s focusing on the expansion of the SLS Waiver as a means of reducing or containing the waiting list for community services. Systems Change featured positioning the state’s network of CCBs as “managed services organizations” and altering the flow of funding from a “fee for service” model to a quasi-capitated model. CCBs are nonprofit organizations that function as the single point of entry to community services for specified service areas. CCBs perform intake and case management as well as contract with service providers. CCBs also furnish various types of waiver services. Under Systems Change, SLS Waiver payments were restructured to a “per member per month” model and CCBs were expected to achieve performance minimums for participant enrollment within the overall state funding allocation. CCBs were given latitude in authorizing individual funding levels.¹

The SLS Waiver was designed to furnish a comparably modest amount of supports to individuals who do not require 24/7 services and live with their families or in other living arrangements. Based on experience with the predecessor CSLA program, state officials believed that furnishing less than comprehensive supports would reduce pressures for costly out-of-home residential services. During the late 1990s, Colorado restricted growth in Comprehensive Waiver services and directed new funding to the SLS Waiver. The SLS Waiver also grew by virtue of the refinancing of state-funded services. Post 2000, the overall growth in Colorado community developmental disabilities services was affected by the downturn in the state’s economy and the state’s constitutional tax and spend limitation. Growth in Comprehensive Waiver services was held largely to accommodating youth aging out of state-funded residential services. This constrained state funding environment was offset somewhat by counties adopting mill levies earmarked for developmental disabilities services.

The operation of the SLS Waiver has varied by CCB. While all CCBs receive the same per participant payment ($16,445/participant/year in 2006), CCBs vary in their practices concerning the amount of services authorized for each participant. Some CCBs authorize a uniform amount while others vary the amount authorized based on individual needs. The program’s $35,000 funding limit is rarely authorized. CCBs also vary with respect to the types of services and supports that are authorized and the degree of participant/family flexibility in service selection. Issues have arisen concerning whether the program’s funding limit creates conflicts between the individual and family with respect to daytime activities, such as community participation and community employment.

State officials report that the SLS Waiver framework has created an atmosphere in which families are more prepared to think in terms of what services and supports they can provide for the individual and what they need the state to provide rather than focusing on what the state alone can provide. SLS also allows Colorado to offer some services to individuals who are on the waiting list for out-of-home placements but not in enough of a crisis situation to be immediately placed in the comprehensive waiver. The overall impact of the SLS Waiver is that more individuals now receive services and more individuals are able to access these services without out-of-home placements. This has also had the effect of reducing per participant costs of services system-wide. Informants also describe the waiver program as a precursor to self-directed services because it allows individuals and families more flexibility in arranging services and choosing providers. While there have been discussions within Colorado concerning implementing full-featured self-direction, the discussions have not resulted in modifications to the SLS Waiver.

In January 2006, there were 1,118 people waiting for Comprehensive waiver services and 2,171 people waiting for SLS Waiver services. Colorado has had a persistent waiting list for community services for many years. Some individuals wait-listed for HCB-DD Waiver services are persons who participate in the SLS Waiver program.

Major Issue(s):

CMS has recently challenged Colorado’s practices in operating its HCBS waiver programs for people with developmental disabilities. In particular, CMS has raised serious questions whether the latitude afforded CCBs in administering waiver services results in inconsistent treatment of program participants CCB-to-CCB. CMS has instructed Colorado to revamp its payments for waiver services. The state is implementing new policies to ensure uniformity in the authorization of services across the state.

In addition, in 2001, Colorado was sued in federal court concerning the waiting list. The aim of this lawsuit was to force the state to expand community residential services by expanding the use of small ICFs/MR. This lawsuit was dismissed by the federal district court in late 2005. The 10th Circuit Court of Appeals upheld the dismissal in 2006.

Statistical Profile

Between 2000 and 2007, total Colorado waiver enrollment will have increased by 22.8 percent. Enrollment in each waiver increased at about the same pace. Since 2000, the proportion of SLS Waiver participants to total Colorado waiver participants has remained roughly the same.

COLORADO WAIVER ENROLLMENT

COLORADO WAIVER EXPENDITURES ($M)

Between 2000 and 2007, total Colorado waiver expenditures will have increased by 63.5 percent. Expenditures leveled off between 2002 and 2005 due to state budget shortfalls. Additional funds were appropriated for 2006 and 2007. The proportion of dollars allocated to SLS Waiver services has ranged between 16-21 percent. Since 2003, the relationship between SLS and Comprehensive Services waiver per participant costs has remained relatively steady at 28-29 percent.

COLORADO EXPENDITURES PER PARTICIPANT

Document Inventory

• Individual Choice Statement Both Waivers, Colorado HCPF Home and Community-Based Services Medicaid Waivers
• Services for People With Disabilities 2006 Legislative Briefing, 372 Lag and Initial for Comprehensive and Support Waivers 2002-2004
• Comprehensive and Support Waiver 2004-2009 renewal applications, and amended 2004-2009 renewal applications

CONNECTICUT

Background Information: Supported Living Services Waiver

In 2005, Connecticut reconfigured its HCBS waiver for individuals with mental retardation. This reconfiguration involved splitting the waiver into two new waivers: the Comprehensive Support Waiver and the Individual and Family Support (IFS) Waiver. In addition, the state also incorporated self-direction features into both waivers.

In part, the reconfiguration also was driven by the settlement agreement that was arrived at in the Arc of Connecticut v. O’Meara waiting list lawsuit. In the settlement agreement, the state agreed to expand the availability of comprehensive services over a 5-year period and take other steps to revamp how waiver services are operated, including assuring that all necessary services are furnished to waiver participants in accordance with CMS State Medicaid Director Letter #4. Dividing the existing waiver into comprehensive and supports waivers was designed to ensure compliance with State Medicaid Director Letter #4.

Once both waivers were approved by CMS, Connecticut assigned waiver participants to one of the two new waivers based on living arrangement and service plan costs. Persons served in licensed community residences or who had service plans in excess of $52,000 were assigned to the Comprehensive Support Waiver. Other individuals were assigned to the IFS Waiver. In addition, Connecticut is stepping up waiver enrollments to include individuals who receive state-funded services but can qualify for Medicaid. Waiting list reduction entails offering waiver services to persons in the emergency and Priority 1 waiting list category (services required within one year). Individuals are offered services in the waiver that will meet their needs.

Both waivers include self-direction features. Connecticut had offered self-direction options under the previous waiver. The new waivers provide for more robust self-direction opportunities. About 800 individuals and families are currently taking advantage of these opportunities under both waivers.

Going forward, Connecticut is revamping how it determines provider waiver rates to improve funding portability by standardizing rates. This will facilitate participants exercising free choice of providers. Previously, Connecticut employed master contracts with providers that made it difficult for individuals to select a different provider. In the past, rates were determined through negotiation with provider agencies and varied considerably. In addition, Connecticut has developed a new individual budgeting tool that, when implemented, will replace the more current method of capping groups of services within each waiver.

Major Issue(s):

In April 2006, Connecticut’s waiver waiting list stood at 782 individuals. Under the terms of the settlement agreement, the state has made progress in reducing the waiting list. The waiting list is kept by urgency or need so individuals selected for the waiver are assigned to one of the two waivers. Statistical Profile

Statistical Profile

Between 2000 and 2006 waiver enrollment increased by 44.7 percent. The decline in comprehensive waiver enrollment in 2006 reflects the transfer of individuals to the IFS Waiver.

CONNECTICUT WAIVER ENROLLMENT

CONNECTICUT WAIVER EXPENDITURES ($M)

Between 2000 and 2006, total Connecticut waiver expenditures increased by 44.7 percent. In 2006, Comprehensive Waiver spending is dropping due to the transfer of participants to the IFS Waiver. The net effect of the implementation of the IFS Waiver is reducing overall per participant waiver expenditures.

CONNECTICUT EXPENDITURES PER PARTICIPANT

Document Inventory

• Individual and Family Support Waiver Applications
• HCFA 372 reports: 2001-2004

FLORIDA

Background Information: FSL Waiver

The Family and Supported Living (FSL) Waiver was developed as part of Florida’s multi-year strategy to reduce the waiting list for home and community services. Florida’s efforts along these lines began in 1999 when the state settled the Prado-Steiman litigation and committed to serve all eligible individuals who were on the waiting list as of June 1999. As a result, the number of individuals receiving HCBS grew from 13,800 in 1999 to over 24,000 in 2004. Florida Governor Jeb Bush was instrumental in securing additional developmental disabilities funding during this period and continues to support year-over funding increases for developmental services. Despite tripling funding for developmental services and substantial expansion of the HCBS waiver, a “post-Prado” waiting list emerged that, at one point, reached about 15,000 individuals. The FSL Waiver was added in large part as a tool to support individuals and families who are on the comprehensive waiver waiting list by offering them a more limited package of in-home and other supports.

The FSL Waiver operates under a fixed dollar limit and offers basic services designed to support individuals who live with their families or who can live independently in the community with modest assistance. In July 2005, the program was expanded to include children as well as adults and the coverage of behavioral services was added. Florida triages waiver enrollment to direct individuals/families who do not require 24/7 services to the FSL Waiver.

The FSL Waiver has two relatively unique features. FSL Waiver participants receive support coordination services through independent support coordination agencies. After the first six months of enrollment, an individual/family may elect to reduce the intensity of support coordination in order to maximize the dollars available to purchase other services and supports. However, in practice, this option has almost never been selected. Second, the waiver includes the coverage of “supported living coaching,” a service designed to provide adults with a personal agent who assists them in meeting the challenges of everyday life. Supported living coaching has been covered in Florida’s comprehensive waiver for more than a decade and has been integral in supporting individuals in regular community living arrangements.

Major Issue(s):

Florida continues to aggressively expand services and supports for people with developmental disabilities. In November 2006, the waiting list stood at 12,011 people. FY 2005-2006 funding is enabling services to be further expanded to reach at least another 7,000 individuals. Statistical Profile

Statistical Profile

The year-over-year growth in waiver participants between 2005 and 2006 reflects a substantial increase in funding approved by the Florida legislature.

FLORIDA WAIVER ENROLLMENT

FLORIDA WAIVER EXPENDITURES ($M)

Florida experienced a 165.9 percent rise in overall waiver expenditures between 2000 and 2005. In 2006, the supports waiver and to a lesser degree the comprehensive waiver, grew another 9.2 percent while the people enrolled grew 27.0 percent in 2006.

FLORIDA EXPENDITURES PER PARTICIPANT

Document Inventory

• 2003 HCBS Waiver Document
• 2004 Family and Supported Living Waiver Document
• November 2005 SPD presentation to Florida Legislature
• Family and Supported Living Waiver Services Directory
• Florida Medicaid 2005 and 2006 Developmental Disabilities Waiver Services Coverage and Limitations Handbooks
• Consumer Guide for the Family and Supported Living Waiver
• Individual Cost Guidelines for Children and Adults
• Have A Job Report, APD Waiting List Should Be Improved for Agency’s Planning and Budgeting Purposes (Report # 06-54 Office of Program Analysis & Governmental Accountability, Florida Legislature)
• HSRI Florida Visit Delmarva QA/QI Overview
• Interagency Quality Council June 2005 Minutes
• Developmental Disabilities Program Office E-Bulletin July 2002 and March 2004
• APD Crisis Review Committee

INDIANA

Background Information: Support Services Waiver

The Indiana Support Services Waiver was launched in 2002. Its purpose is to provide Medicaid-funded services and supports for children and adults with developmental disabilities who reside in the family home or who do not require 24/7 services. The creation of this waiver was an outgrowth of the state’s 317 Plan that aimed to expand and reform community services for people with developmental disabilities. The 317 Plan was developed by a task force made up of consumers, advocates and state officials and received gubernatorial support. The 317 Plan included several steps to refinance day and other services in order to leverage additional federal Medicaid dollars to reduce the state’s spiraling waiting list for community services. System reforms included adopting person-centered planning methods and placing greater stress on supporting individuals in integrated community settings and reducing the state’s over reliance on congregate care facilities.

The Support Services Waiver was designed to principally underwrite the costs of day time services, although the waiver offers some additional services supports. The Supports Services Waiver differs from a more typical supports waiver principally by not offering in-home and family support services. Indiana does not offer personal care services through its Medicaid state plan. Since 2002, the Support Services Waiver has grown to serve about 3,500 individuals. Per capita costs are running at approximately one-half the funding limit (taking into account services funded outside the limit). Going forward, the program may be expanded again to refinance other state-funded services and supports.

The longer-standing comprehensive Developmental Disabilities (DD) Waiver principally (but not exclusively) underwrites services and supports for individuals who require community residential services. In addition to residential services, the DD Waiver offers a more robust array of services than the supports waiver. Between 2001 and 2004, the number of individuals participating in the DD Waiver almost doubled, in part to capture additional federal Medicaid funds but also to underwrite the community placement of individuals from the state’s developmental centers. Indiana closed Muscatatuck Developmental Center and has targeted closure of Fort Wayne Developmental Center (its last state institution) in June 2007. Indiana also has a relatively large private intermediate care facility for the mentally retarded (ICF/MR) sector that currently serves about 3,800 individuals, most of whom reside in smaller group homes.

Major Issue(s):

Despite the implementation of the Support Services Waiver and the rapid expansion of DD Waiver, Indiana continues to experience a major upsurge in demand for community developmental disabilities services and supports. In April 2006, about 14,800 unduplicated persons were waiting for waiver services. In order to meet this demand, the state would have to more than double the number of individuals who receive waiver services. There is especially high demand for comprehensive waiver services, including by individuals who participate in the Support Services Waiver but are seeking residential and other supports. This high unmet demand in the face of the rapid increase in the number of waiver participants over the past several years is explained in part by the fact that waiver growth has been the result of substantial refinancing of services for individuals who were already receiving services in order to overcome shortfalls in state funding rather than expanding the number of people receiving services.

Indiana also has experienced rapid escalation in DD Waiver per participant costs. As a consequence, the state is implementing new cost controls. If these cost containment measures are successful, funds may be freed up to address the waiting list. Statistical Profile

Statistical Profile

Between 2000 and 2006, Indiana waiver enrollment has more than quadrupled. The addition of the Supports Services Waiver accounts for about 64 percent of the growth between 2002 and 2006.

INDIANA WAIVER ENROLLMENT

INDIANA WAIVER EXPENDITURES ($M)

Between 2000 and 2006, the total Indiana waiver expenditures nearly quintupled, in part due to participant growth and in part due to rapidly escalating DD Waiver per capita costs. A relatively small share of the increase in spending is attributable to the implementation of the Supports Services Waiver. In 2006, per participant supports waiver costs were running at 13 percent of comprehensive waiver costs.

INDIANA EXPENDITURES PER PARTICIPANT

Document Inventory

• 2005 Support Service Waiver Renewal Application
• Developmental Disabilities Provider and Case Management Standards

LOUISIANA

Background Information: Supports Waiver and Children’s Choice Waivers

Children’s Choice

The Children’s Choice Waiver was developed in lieu of Louisiana’s implementing the Katie Beckett (TEFR 134) Medicaid eligibility option due to cost concerns. The Children’s Choice waiver is designed to provide a limited array of services and supports to children who meet ICF/MR level of care and live with their families and afford access to Medicaid state plan benefits for a capped number of children. As initially implemented, the program operated under a $7,400/child annual funding limit. The limit was subsequently increased to $15,000 as a result of the efforts of advocacy groups. On average, Children’s Choice waiver participants receive about $12,500/year in Medicaid state plan services in addition to waiver services. As a consequence, the average amount expended on a Children’s Choice participant in 2005 was $21,710. The provision of family support services accounted for about 76 percent of waiver expenditures in 2005.

The New Opportunities Waiver (NOW) also serves children. However, there are 7-8 year wait times for entrance to NOW. A family may elect to accept Children’s Choice enrollment or continue to wait for a NOW opening. When a family that has been wait-listed for NOW accepts enrollment in the Children’s Choice waiver, the child is placed on inactive status on the NOW waiting list. While demand for NOW enrollment remains high, families have expressed satisfaction with the services and supports offered through Children’s Choice.

Supports Waiver

The Supports Waiver was originally intended to enable Louisiana to leverage additional federal Medicaid dollars and apply those dollars to reducing the state’s 13,000 person waiting list. In particular, the waiver design provided for refinancing state-funded adult vocational services and capturing the additional federal funds for application toward waiting list reduction. The Supports Waiver also was intended to create a viable alternative to NOW, which has experienced rapidly escalating costs since it was restructured in 2003.

In the aftermath of Hurricane Katrina, the state was forced to reduce the scope of the Supports Waiver to solely refinancing services for the current 1,800 recipients of state-funded vocational services and cannot deploy the additional federal dollars toward waiting list reduction. Despite this set back, shifting individuals to the Supports Waiver is expected to have positive outcomes in the form of giving individuals greater choices about their type of day support activity, including expanded community employment options. In addition, many of these individuals will now be able to access Medicaid State plan services. CMS approved the Supports Waiver for implementation on July 1, 2006.

Major Issue(s):

Louisiana continues to struggle with an especially large 13,000 person waiting list. In addition, Hurricane Katrina has negatively affected the state budget and, consequently, the capacity to expand services.

Statistical Profile

As can be seen, the number of Louisiana waiver participants has more than doubled since 2000. Nearly all of this growth is attributable to the implementation of the Children’s Choice waiver in 2002 and the addition of the Supports Waiver in 2007.

LOUISIANA WAIVER ENROLLMENT

LOUISIANA WAIVER EXPENDITURES ($M)

Between 2000 and 2007, total Louisiana waiver expenditures will have nearly tripled. Post-2004, the NOW comprehensive waiver experienced a substantial increase in per participant costs. The 2007 addition of the Supports Waiver will have a material effect in reducing overall per person costs.

LOUISIANA EXPENDITURES PER PARTICIPANT

Document Inventory

• Fact Sheet on Louisiana’s HCBS Waiver -- NOW
• Louisiana Children’s Choice Waiver Fact Sheet
• 2006 Application for the Support Waiver
• CMS 372 Reports

MISSOURI

Background Information: Community Supports Waiver

Missouri operates three 1915(c) Home and Community Based Medicaid Waiver programs for individuals with mental retardation or other developmental disabilities: the Comprehensive Waiver; Missouri Children with Developmental Disabilities (MOCDD) Waiver (or the Sarah Jian Lopez Waiver); and Community Supports Waiver (CSW). The MOCDD Waiver is a model waiver enables children with developmental disabilities who are not otherwise eligible for Medicaid to access Medicaid State plan services.

The Comprehensive Waiver supports children and adults with developmental disabilities in the family home and community living arrangements (principally Individualized Supported Living settings for up to three individuals). There is limited utilization of ICF/MR services in Missouri apart from the state-operated Habilitation Centers (Missouri’s large public institutions). In Missouri, counties may establish “SB 40 Boards,” funded by local mill levies. Some SB 40 Boards provide matching funds for waiver services.

The CSW began in July 2003 and was renewed in 2006. The renewal provides for the expansion of CSW to 1,089 people by 2008. CSW was launched to serve as a lower-cost alternative to the comprehensive waiver and as a vehicle to reduce the waiting list. CSW also built on Missouri’s experience in operating state-funded family-centered services. The CSW services match comprehensive waiver services except that CSW does not offer residential services. In addition, CSW is subject to a $22,000/year cost limit that was increased while the MR/DD Comprehensive Waiver was also being renewed this year.

Missouri was one of the first states to install the “employer authority” in its HCBS waivers. Individuals and families are supported in serving as the common-law employers of personal assistance workers. The state employs the Organized Health Care Delivery System mechanism to facilitate consumer-direction of workers, including engaging a fiscal intermediary to perform payroll functions. Missouri is piloting a more robust approach to participant direction through an Independence Plus Pilot Program facilitated by a CMS Real Choice Systems Change grant.

Major Issues/Current Situation:

In December 2005, there were 441 persons waiting for Comprehensive Waiver residential services and another 3,246 persons waiting for CSW. For FY 2005-2006, the Missouri Legislature provided funding to reduce the waiting list by 370 persons, split evenly between both waivers. Progress has been made in reducing the residential services waiting list but the CSW waiting list grew by 16 percent (450 individuals) between December 2004 and December 2005.

A major current focus in Missouri is reducing the number of individuals served at the state’s Habilitation Centers by approximately 25 percent. Statistical Profile

Statistical Profile

During the period 2000-2006, total waiver enrollment in Missouri increased by 10.9 percent. In recent years, CSW has been the principal source of increased waiver enrollment.

MISSOURI WAIVER ENROLLMENT

MISSOURI WAIVER EXPENDITURES ($M)

Between 2000-2006, Missouri’s total HCBS waiver expenditures grew by 48.7 percent. Expenditure growth slowed appreciably in 2003-2004 due to state budget shortfalls.

MISSOURI EXPENDITURES PER PARTICIPANT

Document Inventory

• 2003 CSW application
• Comp & Support Waiver HCFA 372s for 2003, 2004 & 2005
• 2005 Amendment to Support Waiver
• DMR/DD updated expenditure and waiver participant count 2000-2008
• Missouri’s Medicaid Waiver for Persons with Mental Retardation and Developmental Disabilities Fact Sheet
• MR/DD Systems Transformation Initiative

MONTANA

Background Information: Community Supports Waiver

The Community Supports Waiver (CSW) began in 1999 as a distinct waiver service “package” that was nested within Montana’s comprehensive waiver. The package was added as a response to the growing waiting list for services. Many wait-listed individuals lived with their natural families or wanted to live on their own but needed help. Financial resources were limited, so the waiver community supports package was designed to meet the “essential needs of persons in the effort to achieve and maintain successful placements in a variety of settings” and rely heavily on natural supports. The dollar-capped package emphasized maximum flexibility and efficiency in meeting participant needs. Services were designed to be portable -- funds would follow an individual if the person selected a different service provider or moved to a new community. Case managers were asked to support individuals and families in identifying needed services and supports.

The addition of the community supports “package” to the comprehensive waiver was approved in October 1999 based on an understanding between the state and HCFA (now CMS). After the issuance of State Medicaid Director Letter #4, Montana was informed that, in order to continue to offer the package, the state would have to shift community supports to a new waiver. Montana then submitted and CMS approved the CSW in 2001. The original 1999 funding limit of $7,800 per participant was carried forward to the new waiver and remains in effect.

Montana’s Comprehensive Waiver includes a children’s services component that blends in-home and out-of-home services for children with developmental disabilities. It also covers adult residential and daytime services and supported living services for adults.

Major Issue(s):

In 2005, there were 1,372 Montanans waiting for services with an average wait time of 36 months. There were 292 people waiting for the CSW and 1,080 waiting for the comprehensive waiver. Statistical Profile

Statistical Profile

In 2000 and 2001, community support services were provided through the Comprehensive waiver. Between 2000 and 2005, the number of waiver participants increased by 77.8 percent. Since 2002 there has been little change in the number of supports waiver participants.

MONTANA WAIVER ENROLLMENT

MONTANA WAIVER EXPENDITURES ($M)

Between 2000 and 2005, Montana waiver expenditures increased by 72.3 percent. Only a small share of waiver funding is earmarked for the CSW. In 2005, expenditures per support waiver participant were 20.9 percent of comprehensive waiver expenditures. Comprehensive waivers per participant costs are significantly below levels observed in other comprehensive waivers, in part due to the low-cost child component.

MONTANA EXPENDITURES PER PARTICIPANT

Document Inventory

• HCFA 372 Reports
• 2005 Comp Waiver Renewal
• 2003 Support Waiver Renewal
• 2001 Support Waiver Application

NEBRASKA

Background Information: Supports Waiver

Nebraska has three waivers for adults with developmental disabilities. There is also a relatively small HCBS waiver for children with developmental disabilities. In 2003, Nebraska replaced its single comprehensive waiver with three waivers. Two of the replacement waivers include the coverage of 24/7 residential services. The third waiver does not include residential services. The third waiver was designed to accommodate Nebraska’s long-standing policy of offering at least daytime services to youth with developmental disabilities after they leave the special education system. Previously, these individuals were enrolled in the single comprehensive waiver but not afforded access to residential services. The redesign of the previous comprehensive waiver brought Nebraska into compliance with the provisions of CMS State Medicaid Director Letter #4.

In April 2006, Nebraska developed and submitted a new Community Supports Program (CSP) HCBS Waiver to CMS with a July 1, 2006 effective date. The new waiver will serve 100 people in 2007 and scale up to 250 people by 2009. The CSP Waiver is designed to offer alternatives to the traditional model of services currently available through the Health and Human Services Developmental Disabilities System. The traditional model provides for services consisting of day and residential habilitation and respite, provided only by agencies certified as specialized providers of developmental disabilities services. The CSP Waiver would provide for a broader array of services and permit purchasing services from other community (independent or agency) providers. The aim is to give individuals and families more control over the type of services that they receive and the selection of the providers of those services, as well as allowing individuals to purchase services other than habilitative training. The CSP Waiver incorporates self-direction features.

The underlying philosophy of the CSP Waiver is to build upon the individual and family strengths and to strengthen and support informal and formal services already in place. The CSP utilizes a self-directed philosophy, designed to provide choice when determining the services and supports that are needed to maximize the independence of the person with a developmental disability. The individual has the right and responsibility to participate to the greatest extent possible in the development and implementation of his or her plan. The CSP is a funding stream that may be utilized either alone or in conjunction with other non-developmental disabilities funded services and supports, as appropriate for the individual. Individual funding is prior authorized by state staff at the local service area level and is based on the application of an objective assessment process.

Major Issue(s):

Like other states, Nebraska is wrestling with a persistent statewide waiting list. Currently there are 1,178 people waiting for services. There is a waiting list lawsuit that continues to be litigated. The lawsuit challenged both Nebraska’s practice of wait-listing individuals and its methods of authorizing community funding. In addition, the state is striving to strengthen HCBS waiver quality management in response to CMS review of the operation of its waivers. Statistical Profile

Statistical Profile

Between 2000 and 2006, total Nebraska waiver enrollment will have increased by increased by 40.1 percent. In general, waiver expansion since 2003 has been via the day services waiver. Enrollment in the comprehensive waivers has declined slightly.

NEBRASKA WAIVER ENROLLMENT

NEBRASKA WAIVER EXPENDITURES ($M)

Total waiver expenditures will have increased by 73.2 percent between 2000 and 2006. While comprehensive waiver per participant costs have increased significantly year-over-year, the blended per participant cost has remained relatively stable since waiver expansion has been concentrated on the day services waiver.

NEBRASKA EXPENDITURES PER PARTICIPANT

Document Inventory

• Approved waiver applications for residential and day services waivers
• Nebraska Health and Human Services Manual for HCBS and Targeted Case Management (TCM), and the child model waiver
• 2006 Community Supports Program Waiver Application

OHIO

Background Information: Supports Waiver

Ohio launched the Level One waiver in 2003 in order to provide a basic package of community services and supports to children and adults with developmental disabilities who live with their families or otherwise have other supports available to them. The waiver also was designed to leverage county property tax mill levy dollars to obtain additional federal Medicaid dollars to expand services in Ohio. The waiver was one element of Ohio’s Medicaid Reform strategy that has an overall goal of expanding access to community services. Historically, Ohio has relied more extensively on public/private ICF/MR services than is typical nationwide and underutilized the HCBS waiver program to meet the needs of people with developmental disabilities. Medicaid reform envisioned a major expansion of waiver services to meet service demand.

The Level One waiver provides a dollar-limited amount of personal care/homemaker/respite services in addition to day habilitation services and the coverage of home modifications and other equipment/supplies. The waiver also provides for supplemental emergency assistance funding to address situations when a person’s primary caregiver is unable or unavailable to meet the needs of the individual.

The Level One waiver operates side-by-side with the Individual Options (IO) Waiver that offers a full range of community services to participants, including supported living. Ohio is in the last stages of phasing out its Residential Facilities Waiver (RFW). RFW underwrites the costs of services in community residences. RFW services and participants are being shifted to the IO Waiver. In addition, in 2005 Ohio terminated its Medicaid state plan coverage of day habilitation and certain other therapeutic services to address compliance issues raised by CMS. The coverage of day habilitation was added to both the IO and Level One Waivers.

Ohio also is making major changes in the operation of its waivers in response to CMS concerns about inter-county variability in the authorization and delivery of waiver services. All waiver services are delivered through Ohio’s county boards of MR/DD. Counties had employed different policies and procedures in authorizing and paying for waiver services. CMS was concerned that these practices resulted in disparate treatment of waiver participants county-to-county. One element in this effort is instituting a new rate/reimbursement system that is designed to ensure greater uniformity in waiver payments. Ohio has not yet implemented participant-directed features in its waivers.

Major Issue(s):

The extent to which Ohio is satisfying the demand for waiver services is unclear. Waiting lists by waiver are maintained by counties but are not compiled statewide. There is longstanding but still unresolved litigation (Martin v. Taft) concerning access to Medicaid funded services and enabling people served in ICFs/MR to access alternative services in the community. The Martin v. Taft lawsuit was originally filed in federal court in 1989. By September 2006 the comprehensive waiver was serving 11,715 individuals and the support waiver served 3,984. Statistical Profile

Statistical Profile

Between 2000 and 2005, total Ohio waiver enrollment increased by 138.2 percent. By 2008 this rose an additional 76.0 percent with the successful waiver renewals in January 2007 and careful examination of eligibility and waiver membership. As can be seen expansion of the Supports Services Waiver accounts for most of the enrollment growth from 2004 on.

OHIO WAIVER ENROLLMENT

OHIO WAIVER EXPENDITURES ($M)

Ohio waiver expenditures increased by 205.2 percent between 2000 and 2005. In 2005, Level One waiver expenditures accounted for 1.8 percent of total expenditures even though 13.3 percent of all waiver participants were served in the Level One waiver. Level One waiver per participant expenditures were 11.9 percent of IO Waiver per participant spending. The increased implementation of the Level One waiver resulted in notable reduction in overall spending per waiver participant. These same trends are projected to continue with 95.9 percent additional total waiver expenditure expansion by 2008. The Level One waiver will then account for 13.5 percent of total expenditures and 29.3 percent of all waiver participants were served in the Support Services Waiver.

OHIO EXPENDITURES PER PARTICIPANT

Document Inventory

• Individual Options (Comprehensive) Waiver 2004
• 2002 and 2003 Level One (Support) Waiver
• Residential Facility Waiver (RFW) (comp waiver) 2000
• Community Access Model Initial Waiver 2004
• April 4, 2006 Teleconference Big Picture Perspective
• 2006 Level One Waiver Renewal

OKLAHOMA

Background Information: Supports Waiver

Oklahoma launched its two In-Home Support Waivers in 1999. The implementation of these waivers was based on a 1997 study of Oklahoma’s waiting list conducted by Oklahoma State University. The study surveyed the entire waiting list to identify the services people most needed. The findings showed that 82 percent of the individuals on the waiting list lived in their own or family homes and that the most needed services were help with daily living activities, respite care, and vocational services. The purpose of the waivers was to reduce the waiting list by offering limited supports to adults and children who lived with their families. The rationale for and design of both In-Home Support Waivers was influenced by Colorado’s SLS Waiver.

Oklahoma also operates two comprehensive waivers: the Community Waiver and the Homeward Bound Waiver. The latter waiver serves persons placed from state institutions into the community as a result of the Homeward Bound et al. v. The Hissom Memorial Center lawsuit. Approximately 950 individuals are served in this waiver. Both comprehensive waivers provide a full array of services, including out-of-home around-the-clock residential supports.

Both supports waivers operate under funding limits. The adult waiver limit is approximately $6,000 greater than the child waiver limit. The difference in the two limits stems from: (a) the fact that special education services are furnished to children but adults require waiver-funded day supports; and (b) children have access to more robust Medicaid state plan benefits through the Early and Periodic Screening, Diagnosis, and Treatment program. In 2004, average annual participant outlays were approximately $3,300 below the adult waiver funding cap but roughly at the cap for the child waiver.

The In-Home Supports Waiver programs operate differently from the comprehensive waivers. Individuals and families have flexibility in selecting services and supports, based on the person-centered plan. Participants may train their own providers and have the authority to sign a “Certificate of Competency” for the provider in lieu of the provider completing state mandated training, if the family chooses to exercise this option. Case management required contacts in the In-Home Support Waiver program are less intensive than the comprehensive waivers. This reduced oversight role allows a higher caseload ratios for case managers of individuals in the In-Home Support Waiver programs. State officials observe that the supports waivers have helped lower the average cost per participant for services while affording more flexibility in tailoring services to consumers and families. The supports waivers have proven beneficial in shifting their system to a supports model that assists individuals to remain in their own or family home. The Community Waiver has come to be the waiver used in emergency situations and when a person has complex and/or residential needs.

Oklahoma also operates the Family Support Assistance Payment Program, which provides a cash payment to families who are raising children with developmental disabilities under the age of 18. In June 2005, this program was furnishing assistance to 1,735 children. In addition, in 2005, Oklahoma implemented the “Katie Beckett” Medicaid eligibility option to extend Medicaid benefits to children with disabilities by waiving the deeming of parental income. As a result of this program, there are 950 children living at home with their families.

Once an individual is enrolled in the In-Home Support Waiver, additional supports can be provided on a temporary basis to deal with emergencies. While the state does not place a time limit on these additional funds, the intent of the additional funding is to maintain the person’s current situation. If, over time, the In-Home Support Waiver programs can no longer meet the needs of the individual, the person may potentially move to the Community Waiver. Decisions about movement from one waiver to another are made on an individual basis. Oklahoma reserves Community Waiver capacity to serve high-priority individuals identified as needing emergency placement.

Oklahoma also operates the Family Support Assistance Payment Program, which provides a cash payment to families who are raising children with developmental disabilities under the age of 18. In June 2005, this program was furnishing assistance to 1,735 children. In addition, in 2005, Oklahoma implemented the “Katie Beckett” Medicaid eligibility option to extend Medicaid benefits to children with disabilities by waiving the deeming of parental income. As a result of this program, there are 950 children living at home with their families.

Major Issue(s):

In November 2006, there were 4,200 people on the waiting list. In its 2005 session, the Oklahoma Legislature appropriated additional funds to move 2,148 people off the waiting list in FY 2005-2006, principally by expanding the In-Home Supports Waivers. As of December 2006, the number of people on the waiting list had been reduced to 3,074. Statistical Profile

Statistical Profile

As can be seen, waiver enrollment in Oklahoma was flat between 2002 and 2005. In 2006, enrollment grew by 2,148 persons (about 70.6 percent) as a result of additional funds appropriated to reduce the waiting list.

OKLAHOMA WAIVER ENROLLMENT

OKLAHOMA WAIVER EXPENDITURES ($M)

Between 2002 and 2005, total Oklahoma waiver funding was largely unchanged. Comprehensive waiver per participant costs reflect the relatively high costs associated with operating the Homeward Bound waiver. Both waivers total spending increased as a result of the waiting list reduction initiative but the In-Home Support Waiver covered most of the new people.

OKLAHOMA EXPENDITURES PER PARTICIPANT

Document Inventory

• 2006 Community and Homeward Bound Waiver renewal applications
• HCFA 372 annual reports
• 2005 amendment In-Home Support Waiver for Children
• Two Brochures Building Bridges of Support One Person At A Time (General) and In-Home Supports Waiver 2006
• SSI Disabled Children’s Program Family Support Division Brochure
• TEFRA Helping Oklahoma Children with Disabilities 2006 Brochure
• Oklahoma Developmental Disabilities Council 5 Year Plan 2006
• Rules Chapter 40 Developmental Disabilities General Provisions 2006
• 2006 Quality Management Strategy
• Principles of Individual Planning
• Building Bridges of Support One Person At A Time Annual Report 2005
• OKDHS Hearings Brochure
• Consumer Service Evaluation Brochure
• Rules 2006 for: Part 7 Assistance Program, Quality Assurance
• Contract Performance Surveys and Administrative Inquiries
• Volunteer Guardianship Program
• Pre-Employment Screening for Community Service Workers
• Procedure for Reporting Suspected Abuse, Neglect, Verbal Abuse, Caretaker Misconduct, and Exploitation, Office of Client Advocacy Investigation Protocols
• Human Rights Committee, Community Staff Training, Staff Providing Supports Through the In-home Support Waiver, Training for Case Managers, Program Coordinator Training, Medication Administration Training, Medication, and Health Related Services
• Developmental Disabilities Services Division Heath Alert 2nd Quarter 2006

OREGON

Background Information: Supports Waiver

Oregon’s Supports Services for Adults Waiver was a direct outgrowth of the Staley et al. v. Kitzhaber lawsuit that was filed in January 2000. The lawsuit alleged that Oregon’s failure to provide Medicaid services with reasonable promptness to eligible individuals violated federal Medicaid law and the Americans with Disabilities Act. The lawsuit stemmed from the large waiting list for services. In December 2000, the federal court approved a settlement agreement that was based on the Universal Access Plan which, in turn, had been previously proposed as a means of ensuring that all eligible adults with developmental disabilities receive at least a basic level of supports. The settlement agreement committed Oregon to design and implement the supports waiver and eliminate its waiting list for services over a multi-year period.² The original settlement provided for eliminating the waiting list by the 2007-2009 biennium by extending services to an additional 4,600 individuals. Due to budgetary shortfalls, the agreement was modified in 2004 to stretch out the period for eliminating the waiting list to the 2009-2011 biennium.

Oregon was influenced by Colorado’s waiver design of operating separate supports and comprehensive waivers. The Supports Services Waiver design also was significantly influenced by self-determination principles. System stakeholders played a critical role in shaping the waiver. The state and stakeholders saw the new waiver as an opportunity to make improvements in service delivery and stakeholders continue to be actively involved through the Staley Implementation Group. Consumers were already seeking more flexible alternatives to the traditional services system including options to self-direct services. The Supports Services Waiver offers flexible in-home supports to consumers and families that are intended to prevent out-of-home placement and thus reduce comprehensive waiver enrollment pressures. Consumers and families enter into contracts directly with providers, affording a high degree of choice and control over the nature of the services. The new waiver also adopted a different approach to management through the development of Support Service Brokerages to assist the person in the development of a plan, including an individualized budget, and identifying service providers. The Supports Brokerage Personal Agent facilitates person-centered planning, assists participants in selecting and purchasing services, performs day to day oversight and monitoring of the services, and furnishes additional assistance to help participants access other services. Oregon counties (which provide full range case management in the Comprehensive Waiver) perform play a more limited role in the Supports Services Waiver. Counties perform eligibility reviews, approve the individual plan for Medicaid compliance, provide protective services, and assist in crisis management. These services are billed under Medicaid administration.

The waiver operates under a $20,000 per participant funding cap. Waiver participants are eligible for a base funding allotment of $9,600. Individuals with more intensive support needs may receive additional funding. The need for additional funding is determined by administering the BCSI.³ In August 2005, 34 percent of participants had plans that were funded in excess of $9,600. In addition, Oregon provides that “emergent services” in excess of the $20,000 cap may be authorized for individuals in crisis. In August 2005, 4 percent of service plans exceeded $20,000. Also in August 2005, plan authorizations averaged $767/participant/month ($9,204 per year) while average monthly expenditures per participant $613/month ($7,356 per year).

Some 95 percent of waiver participants have intellectual disabilities and frequently have multiple disabilities (e.g., behavior dysfunction and other health impairments). About 79 percent of participants live with their families; 9 percent live on their own. Two-thirds of waiver participants are between the ages of 21 and 40.

Order of selection criteria regulate the selection of individuals for entrance to the waiver. Currently, the order of selection is: (a) individuals experiencing crisis; (b) persons with aging (over 75) caregivers; (c) persons aging out of Oregon’s two model waivers for children; (d) persons transitioning from school; and, (e) persons on the general waiting list. Since inception and through October 2005, 1,553 individuals have entered the waiver from the adult waiting list. Other enrollees included persons who entered the waiver from other programs (e.g., child family support, high school transition) where funding would have stopped due to aging out or other reasons. Absent the waiver, 56 percent of enrollees would have remained on the waiting list or been wait-listed. About 44 percent of participants are persons who had been receiving services that qualified for waiver funding.

Waiver expenditures are concentrated in two waiver services: community living supports (a form of in-home supports) (39 percent) and community inclusion supports (a form of day supports) (39 percent). Respite care accounts for 8 percent of expenditures, supported employment for 7 percent and non-medical transportation for 6 percent. All other covered services account for only 1 percent of expenditures.

The Oregon Comprehensive Supports Waiver furnishes services primarily to individuals who reside in various types of community residential settings, including group homes and supported living arrangements. A small number of waiver participants are served in the family home. The Comprehensive Supports Waiver does not include self-direction features. Oregon operates only one small public institution that serves approximately 40 individuals. There are no privately-operated ICFs/MR in Oregon. Under the terms of the Staley settlement, persons who experience crisis must be offered Comprehensive Supports Waiver services. Since inception, 221 Supports Waiver participants have transitioned to the Comprehensive Supports Waiver. Oregon also operates two small model waivers for children: one supports children who have intensive behavioral challenges while the other serves children with extraordinary medical needs.

In 2004, there were 2,270 people waiting for Oregon’s Supports Services Adult Waiver. In 2006, the number waiting was somewhat lower -- about 2,000 individuals. The number of persons waiting for the Comprehensive Supports waiver was 1,500.

Major Issue(s):

System-wide, Oregon is experiencing a significant increase in the number of individuals experiencing crisis. This is causing funding stress within both waivers. Statistical Profile

Statistical Profile

Between 2000 and 2005, total Oregon waiver enrollment increased by 55.8 percent. The next three years through 2008 adds another 66.3 percent. As can be seen expansion of the Supports Services Waiver accounts for all net enrollment growth since 2002.

OREGON WAIVER ENROLLMENT

OREGON WAIVER EXPENDITURES ($M)

In Oregon, total waiver expenditures increased by 46.4 percent between 2000 and 2005. Expenditure growth slowed in 2003, due to effects of the downturn in the Oregon economy. In 2005, Support Services Waiver expenditures accounted for 8.2 percent of total expenditures even though more than one-third of all waiver participants were served in the Support Services Waiver. Supports Services Waiver per participant expenditures were 15.3 percent of Comprehensive Waiver per participant spending. The implementation of the Support Services Waiver resulted in stabilizing overall spending per waiver participant. These same trends are projected to continue with 22.2 percent additional total waiver expenditure growth by 2008. The Support Services Waiver will then account for 13.2 percent of total expenditures even though 53.0 percent of all waiver participants were served in the Support Services Waiver.

OREGON EXPENDITURES PER PARTICIPANT