“In Colorado we have approximately 71,000 individuals who are dually eligible for both Medicaid and Medicare. And those individuals actually represent 13% of our total Medicaid population. Those dual eligible individuals who are receiving Medicaid benefits account for 43 % of our Medicaid budget. That is about 1.2 billion dollars. It’s quite a large expenditure for a relatively small percentage of the population. Now that being said, these are very high need individuals. 60% of the individuals who are dual eligible are elderly, and 40% are actually individuals with some sort of a disability. So they have high needs and we want to make sure that we are serving them appropriately. 60 percent of those individuals actually have multiple chronic physical conditions and 20 % have more than one mental or cognitive condition. We want to make sure that we are coordinating care for them, making sure that they get all the services they need to deal with these intense physical and behavioral health conditions that they have.”
I’m aware that some states have started to design models for this Medicare/Medicaid integration. Which state would Colorado be modeling its design after and why?
“Now there are some states that are doing an excellent job in terms of redesigning their delivery system – with a focus on accountable care organizations and health homes and I’d say two of the leading states in the country are North Carolina and Vermont. Now they might not be specifically doing something around the dual eligibles but their work in coordinating care is so significant that that is really what we’re modeling ourselves after.”
In what way?
“Vermont has something called the Blueprint for Health and they have a very strong system they’ve designed that’s very integrated and systematic and has community healthcare coordinators who are very effective and work across different insurance products as well. So that’s one example. In North Carolina, their model is built on a very strong Medical Home model – and so that’s something we’ve built into our ACC for that very reason based on North Carolina’s success.”
What are the greatest challenges you foresee in creating this redesign of Medicaid and Medicare?
“I’d say some of the greatest challenges are making sure that we leverage the infrastructures we’ve already built and that they’re seamless connections. As I mentioned earlier, the idea that we do have a good PACE program in Colorado, we do have Medicare special needs plans, yet there are many people who are still in that uncoordinated fee for service system.We need to make sure we’re tying those things together and leveraging them appropriately. So that’s one challenge. I think making sure that we have an adequate provider network. Ideally, providers would take both Medicaid and Medicare so they can do a better job coordinating care for their patients.”
Senator, what do you view as the biggest challenges facing the Health Benefit Exchange in Colorado?
“I think the two biggest challenges are the timelines and finding the money that it’s going to take to develop an appropriate IT system. Colorado’s had a pretty spotty record in the past with some of their IT systems. We need to have a good system for the Exchange itself, but in addition to that, there needs to be a good eligibility determination process and the reality is our current Colorado Benefits Management System is not going to be up to the task I don’t think. There are some challenges because CBMS already integrates eligibility determination for Medicaid and for human services programs. A lot of states haven’t gone that far to integrate those eligibilities but we have and as a result it’s not just making the distinction between Medicaid and those served in the Exchange because of all the other human services components. You can’t just throw them together.”
What is your opinion of the federal government throwing it to the states to establish their own essential health benefits?
“It sure does create more challenges for the state because we were assuming that there would be some really good guidance but I don’t think there is. So at the same the time the exchange itself is being developed, the rules around what that package is going to look like are working and right now the commissioner of insurance is having some town hall kinds of meetings to try and help determine what those essential benefits will be for Colorado because the exchange is really a marketplace and the commissioner of insurance still has the same role as before.”
Do you have an opinion on whether the Affordable Care Act will stand?
“I believe it will. But whether or not it does, we have said all along our intent is to create an Exchange regardless of what happened it would certainly be harder to deal with some of the financing ultimately of those participants who would be included in the Exchange because the share of the participants is anticipated to be receiving some kind of subsidy. This is the place where they should be getting their insurance.”
In Part I of her interview with Catherine Strode, Senator Boyd discussed asked the proposed transfer of services for the elderly and services for people with developmental disabilities to the Department of Healthcare Policy and Financing.
Senator Boyd, What do you think about the potential transfer and will you be sponsoring a bill to authorize the transfer?
“I will confirm. I will carry a Bill. The intent of the Bill, as I see it, is to initially consolidate the administrative function in one department so that HCPF has responsibility for everything Medicaid. And as I see it, that was just Phase One of the whole process. There would be no change immediately in the way services are delivered. I think there is fear about that. But Phase Two would be a very extensive stakeholder process that would determine the best options for service delivery in the future which might take a year or even longer. But there is that second phase planned. So other than who the employees relate to, which department cuts their check, there should not be any immediate change in service delivery and I think that’s one thing people are really worried about. There are those who are saying ‘you are putting the cart before the horse.’ I think the sooner that we can at least consolidate those administrative functions, the better. I know HCPF is doing a lot of consumer and stakeholder work and they’re doing more in the near term.”
Your bill, then, would strictly address Phase One, that is, the administrative transfer of duties?
“I understand it likely will do Phase One and have language directing Phase Two.”
What do you think could be the benefits of the HCPF transfer administratively?
“I think for openers we as a state are required to have one Medicaid agency, one agency that handles all of the Medicaid. Because at the time that Medicaid came into existence, HCPF didn’t exist. It was the Department of Health and Human Services and everything was in one department. But when HCPF was formed, they took the financial function and Medicaid. But it was worked out so the service delivery happened through human services. So this is trying to get back to having a consolidation of what seems to be a better way of organizing so Medicaid is all in one place. And as we look at long term care, which is the big and growing issue and will be the huge issue in the not too distant future with the explosion of aging baby boomers, we’ve got to be looking very carefully at how we deliver long term care services. I think it would create some really important efficiencies.”
Which health care bills being presented in this legislative session will have the greatest impact?
“Of those that are in the hopper right now, I would say this bill for the consolidation of those programs and HCPF.”
How do you think this bill will affect the future of Medicaid in the state of Colorado?
“Hopefully it would make Medicaid care more efficiently managed.”
Coloradans with disabilities have long faced the complex issue of accessing Medicaid benefits while not crossing the fine line of generating too much income as to render them ineligible. They’ve also found themselves in instances where they’ve fallen through the cracks coverage-wise while transitioning from Medicaid to Medicare during long wait periods or where they wish to retain Medicaid coverage as a back up to Medicare coverage. Luckily, a new Medicaid Buy-in Program for Working Adults with Disabilities is on the brink of release and will hopefully provide a solution for these situations.
Beginning in March 1, 2012, working Coloradans ages 16 through 64 who have a disability will be able to apply for the Medicaid Buy-in Program for Working Adults by completing an application through their local regional county office, online at Colorado.gov/PEAK (or call 1-800-221-3943 for information). Accepted applicants will be offered the chance to pay monthly premiums based on their income for Medicaid benefits such as office visits, hospitalizations, x-rays, home health services, durable medical equipment and prescription medications. There is, however, a cap on how much working adults with disabilities may generate in income. Applicants may earn up to 450% of the federal poverty line (roughly $45,009). Income disregards will be applied prior to determining an applicant’s income for the purposes of this program.
To learn more about this program and how it may benefit you please check out this Fact Sheet and, if you have questions, please contact Kimberley Smith with the Colorado Department of Health Care and Financing Policy (303-866-3991/800-659-2656 TTY/TDD).
Note: This blog was written/edited by AdvocacyDenver with resource and editing assistance from the Colorado Department of Health Care Policy and Financing.
Beginning in 1976, AdvocacyDenver (formerly ARC of Denver) has promoted the belief that individuals with disabilities belong in the community and have a fundamental moral, civil and constitutional right to be fully included and actively participate in all aspects of society. The National organization adopted this belief in 1998.
The Individuals with Disabilities Education Act (IDEA) guarantees our children a right to a free, appropriate public education (FAPE) in the least restrictive environment (LRE). Certainly the Denver Public Schools (DPS) provides our children with disabilities a free education; the ongoing debate is in relation to how DPS implements the IDEA, what is appropriate and moreover what is the least restrictive environment. The IDEA provides that:
“To the maximum extent appropriate, children with disabilities will be educated with children who are not disabled, and special classes, separate schooling, or other removal of children from the regular educational environment occurs only when the nature or severity of the disability is such that education in regular classes with the use of supplementary aids and services cannot be achieved satisfactorily.”
Supplementary aids and services means aids, services, and other supports that are provided in accordance with the child’s Individualized Education Program (IEP). Supplementary aids and services must be based on the child’s individual needs and could include: supports to address environmental needs, special equipment, additional adult support, planning time for staff, accommodations in the way subject matter is presented, assignment modifications, test adaptations social interaction support and staff training. In keeping with the spirit and intent of the IDEA, these supports/services are to be provided in general education classes, other education-related settings, and in extracurricular and nonacademic settings to allow the child to be educated with nondisabled peers.
Denver Public Schools asserts that they are in compliance with federal law:
“Department of Special Education is committed to providing an educational experience based upon the individual needs of each child as prescribed and defined by the federal Individual with Disabilities Improvement and the state Exceptional Children’s Education Act. The Department provides specialized instruction for students to minimize the impact of their disability through a continuum of services, ranging from services provided in the general education classroom to fully contained classroom settings.”
AdvocacyDenver asserts that there is a disconnect between what the District outlines in written statements and the actual day-to-day practice of the District and schools. Significant areas of ongoing concern in relation to DPS include, but aren’t limited, to the following:
- The standard practice to assign students with cognitive disabilities to center programs;.
- The standard practice to limit the level of support/services (one-size-fits-all) for children with mild/moderate disabilities enrolled in charter, contract, redesigned, turnaround and/or neighborhood schools;
- The standard practice to provide school principals with the authority to determine whether to accept or refuse a student with a disability for enrollment.
DPS Practice Number 1: Standard assignment of students with cognitive disabilities to center programs.
The district does not exhaust building level interventions or less restrictive educational settings. The IDEA asserts that special classes, separate schooling, or other removal of our children from the regular educational environment occurs only when the nature or severity of the disability is such that education in regular classes with the use of supplementary aids and services cannot be achieved satisfactorily. Parents report that in most cases the school staff are reluctant to try anything outside the norm to accommodate a student with a cognitive disability. In fact, outside the IEP process, school staff will typically tell the parent, exactly what services they can/will provide and the setting in which the services will be provided (e.g. I pull kids out for resource). In some cases school staff will say they would love to have the student attend the school but district special education administration will not provide them with the resources (e.g. paraprofessional staff) to support the student in the general education setting. In this instance school staff is telling the absolute truth. DPS Student Services Program Managers have been carefully coached to categorically deny paraprofessional support and to phrase it in such a way as to not be in blatant violation of IDEA. In addition, it would appear that DPS has crafted a standard and IDEA compliant rationale statement to be included on the IEP of every student who receives services outside the general education setting:
“In order to meet (child’s name) needs in the areas of (name areas, e.g. behavior, math), (child’s name) requires services outside the general classroom as described in his/her IEP.”
Furthermore, many center program students have few if any opportunities to participate in academic, non-academic or school related activities with typical peers. If the short yellow bus transports the student to and from school and the school offers any before or after school activities (e.g. clubs), be assured that the center program student will not be afforded an opportunity to participate in such activities because the District does not offer center program students with before/after school activity transportation. Some children never see the light of day outside of a segregated school setting. In fact, too often inclusive opportunities are limited to eating your lunch in close proximity to nondisabled students because of the mandatory assignment to sit at the lunch table with the center program paraprofessional and other center program students. Both the district and schools offer different excuses. The District asserts that because of school autonomy they can make recommendations about best practices/LRE, but have no authority over school staff or principals. School staff says that the district doesn’t provide enough paraprofessional support staff, or, general education teachers aren’t receptive to including children with more significant disabilities. There is a certain amount of truth to what each side is saying. The district is not terribly generous with resources and sometimes general education teachers do not welcome children with more significant needs. In some instances, special education teachers do not share the value that all children should have an opportunity to participate in activities with typical peers. Student Services leadership is correct in stating that each DPS school has a certain amount of autonomy. The school principal sets the tone for the building and this leader can either encourage segregated programming (separate, “but equal”) or lead a model where different abilities are celebrated and all children are woven into the tapestry of the school community.
DPS Standard Practice Number 2: The practice to limit the level of support/services (one-size-fits-all) for children with mild/moderate disabilities enrolled in charter, contract, magnet, redesigned, turnaround and/or neighborhood schools.
IDEA requires that the school district provide a continuum of services and that decisions be based on the individual needs of the child. The DPS Board of Education has policies (see policy IHBA and IHBA-R Children or Youth with Educational Disabilities) and the Department of Special Education has adopted procedures that comply with federal law. DPS policy IHBA states:
“Denver Public Schools believes that inclusive school communities are those in which all students are valued members of the educational environment and all students have access to, and participate in, opportunities within the school and community at large, based on their strengths, talents and individual needs.”
Yet parents and advocates report that rather than defining services according to the individual needs of the child, school IEP teams frequently craft the IEP according to building level resources or preferred practice. It is not uncommon for the staff at one school to say “we pull kids out and serve them in the resource room” and for the staff at a different school to say “we don’t offer any pull-out, all kids are served in the general classroom” and so on. School staff will frequently say that the district does not provide them with the resources to facilitate a basic continuum of services (consultation, direct services in the general education classroom, direct services outside the general education classroom). Furthermore, there are disparities between the areas/skills an IEP team will target for a student to work on (e.g. social skills/social development). The IEP team at one school will assert that services need only be designed to facilitate the students progress/access to academic programming, while the IEP team at another school will define specific goals in relation to social development and identify the school psychologist/social worker as the provider. Again, school staff will confide that such decisions are contingent on the amount of time a mental health specialist (psychologist/social worker) is assigned to the school; moreover, the individual provider’s level of comfort and training in facilitating mental health services for students with differing disabilities.
DPS special education leadership point to the different department procedures as evidence of compliance but also confirm parent and advocate observations are correct and again, assert disparities are largely a result of school autonomy. School principals are given ultimate authority to determine staffing (e.g. Do I want to purchase 4 hours or 20 hours of psychological/social work services a week.) as well as programming decisions. The school principal establishes the culture of the school and is in a key position to welcome all learners and promote a model that allows for instruction and services based on individual needs. Unfortunately an increasing number of parents and advocates report (and some educators confide) that DPS gives preference to a breed of school principals who deliberately, or at time naively encourage a single model for servicing students with disabilities.
DPS Standard Practice Number 3: The practice to provide school principals with the authority to determine whether to accept or refuse to enroll a student with a disability.
Colorado law regarding school choice allows each school district to adopt policies and procedures in relation to choice for resident and non-resident students. DPS Board of Education policies JC Pupil Assignment and JC-R All Schools – Pupil Assignment Procedures (Revised June 30, 2010) appropriately discuss schools of choice, transfer and assignment procedures.
The issue at hand is the way in which Board policy is being interpreted and implemented. First, it is important to state that DPS’s school model is a moving target. It would appear that within the next few years the district will have eliminated neighborhood schools and instead families will “apply” to have their child enroll at the contract, charter, magnet, special program, turnaround or redesigned school down the street, or across the city. The District does not provide a common application and enrollment process for all of the different school models, except, the Schools of Choice Office has posted two brochures on their web, one discussing procedures for nondisabled students; the second titled “Traditional Choice Application Students with Disabilities.” It is here where the District states: “approval for enrollment of a student with a disability is on the condition that the services outlined in the student’s plan (IEP or Section 504 plan) can be delivered in the school,” and that the principal and the special education teacher (for whom the principal conducts employee appraisals of the school staff) who make this determination. Board of Education policy appropriately does not provide school principals the authority to arbitrarily refuse students with disabilities. However, the fact that students with disabilities are clearly underrepresented in the District’s Charter and magnet schools is likely a direct result of blatantly discriminatory department procedures and the way in which those procedures are applied.
Equally worrisome,, an increasing number of parents report (and some educators confide) that if a child does not perform at an expected level (academically or behaviorally) some school principals will counsel parents to withdraw their child from the school. It is important to remember that contract, charter, magnet, special program, turnaround, redesigned and neighborhood schools are all public schools and as such, have an obligation to serve students with disabilities. Albeit, they do not have to provide a full continuum, but it is expected they will provide basic supports according to the individual needs of the student.
It shall be the priority for AdvocacyDenver (Agency and educational advocates) staff (educational advocates) to support DPS parents whose children are:
- systematically placed in a center program; or,
- not appropriately being served because the IEP team has failed to consider the type and location of services according to the individual needs of the child; or
- denied enrollment or are encouraged to withdraw enrollment from a DPS contract, charter, magnet, special program, turnaround, redesigned and/or neighborhood school.
Educational advocates will request copies of educational records, in addition to any and all documentation from all members of school staff and District administrators (e.g. emails, data collection, notes) that discuss IEP, program location, school assignment and/or enrollment decisions.
Educational advocates will exhaust school and administrative remedies to resolve issues. When appropriate, an educational advocate will discuss and encourage families to file formal complaints with the appropriate state or federal agency. Agency leadership and legal counsel will determine when and if class action litigation would be appropriate.
Agency leadership and staff will continue to discuss and work with DPS Student Services, other district leadership, DPS Board of Education, and other state and federal agencies to reach resolution regarding systemic concerns.
Two-thousand eleven was quite a busy year here at AdvocacyDenver. Individual advocacy was in great demand and each advocate pulled through (and continues to do so!) to provide quality advocacy support to individuals with disabilities and their families. To analyze the amount and types of support provided, AdvocacyDenver tracks its core programming through the use of a Clients Database. This gives us insight to the trends and barriers confronting individuals with disabilities residing in Denver and enables us to plan strategically. Here’s a snapshot of what 2011 looked like:
How many clients did we support in 2011 and what type of support was that?
The graph summarizes the overall advocacy support provided by AdvocacyDenver in 2011. The combined bars in the graph identify 269 clients (new and on-going) that received different forms of advocacy support in 2011.
How many individual advocacy issues did AdvocacyDenver support in 2011?
The graph summarizes the advocacy issues addressed by AdvocacyDenver as a whole in 2011. The total number of issues addressed in 2011 is 289.
For more information about the types of individual advocacy trends in 2011 please contact Catherine Strode at email@example.com.
We have done some serious website re-modeling here at AdvocacyDenver. We’re pleased to share the new design with you and we hope you find it useful. Our intentions behind the re-design were to improve the functionality of the website and increase the quality of the information and tools it offers to both prospective and existing clients and folks interested in getting involved with us
Individuals and their families now have easy access to information that is important and relevant to you! This includes:
- Information on individual advocacy programs for children and adults with intellectual or developmental disabilities (I/DD) and their families. These pages also include up to date agency and resource listings across various areas of advocacy;
- current calendar of local events and meetings in the Denver Metro Area;
- an overview of our online, interactive webinar offerings;
- important potential Colorado bills, including those in health care, that directly impact individuals with I/DD;
- information on our unique Center for Special Education Law;
- …and much more!
Also, there is plenty of information for people, foundations, or corporations interested in getting involved with AdvocacyDenver and staying in the loop about what it is doing in the community. This includes:
- Becoming an AdvocacyDenver member;
- learning about current volunteer/intern opportunities;
- getting updates on important news and policy headlines, upcoming events and educational opportunities, and organizational news;
- seeing how your donations make a differenceto AdvocacyDenver and the community it serves;
- …and much more!
So please take a look around and enjoy!
Denver, Colorado—Recently, AdvocacyDenver was awarded a $30,000 grant from the Daniels Fund to support its core program, individual advocacy. AdvocacyDenver features seven advocates who provide individual, technical, and referral-based advocacy assistance to individuals with intellectual or developmental disabilities (I/DD) and their families in Denver County.
Advocates work alongside clients to gain access to quality supports and resources while navigating complex systems, such as health care, education, employment, and housing. With the support from advocates, individuals with I/DD and their families develop strong self-advocacy skills, empowering them to improve the quality of their own lives.
For 2011, AdvocacyDenver estimates it will have taken on 200 new clients through its referral and intake process for advocacy requests providing them with a wide range of assistance and resources for various advocacy issues. Among all of these clients, AdvocacyDenver anticipates addressing an estimated 275 unique advocacy issues through the end of 2011.
Advocate Alexandra Andrews says, “AdvocacyDenver receives requests from a very high number of individuals that need assistance and guidance in varying fields. This grant will bring us closer to meeting their needs.”
Bill Daniels, a pioneer in cable television known for his kindness and generosity to those in need, established the Daniels Fund to provide grants and scholarships in Colorado, New Mexico, Utah, and Wyoming. For more information, please visit www.danielsfund.org