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The Texas Department of Assistive and Rehabilitative Services (DARS) has released their Legislative Appropriations Request (LAR). The full document can be found here: http://www.dars.state.tx.us/reports/lar2016_2017.pdf . This document represents the agency’s budget request for fiscal years 2016 and 2017 (taken together these are a biennium). This is the first step in the budget process, where the agency identifies what it needs and what special requests that it has. This will be matched in the beginning of the Legislative session in the spring of 2015 with a document by the Legislative Budget Board, which will be their view of what the agency needs. The agency will then spend the spring testifying before the Texas Legislature to secure its appropriations.

This is an extremely important document because there may very well be more significant changes on the horizon for the Early Childhood Intervention (ECI) program. Reading through the document, DARS tells us that in fiscal year (FY) 2013, ECI served approximately 25,000 children per month. In their LAR, they are projecting to serve a little over 22,800 by FY2017. This represents an almost 9 percent decrease. During this time, the average monthly number of hours of service per child per month is projected to increase from 2.61 hours/month to 2.93.

In their LAR, DARS is projecting that ECI will essentially maintain its budget in FY 2016, but will see a reduction of more than 15% during FY2017. In other words, in their baseline budget request DARS is telling us that they are projecting a decrease in funding and are projecting that they will need to serve fewer Texans between the ages of birth and three years old.

As a result of this, DARS is making two special requests for funding in their LAR on behalf of the ECI program. The first is a request of over $25,000,000 over the biennium just to maintain the projected FY2015 case levels. From page 189 of the LAR: “Federal IDEA Part C funding available to fund the ECI system in Texas has remained flat in recent history. However, ECI program costs associated with federal
requirements and not reimbursed by Medicaid has resulted in the agency using more federal IDEA Part C funding for allowable program expenses than projected. As DARS uses more IDEA Part C funding in fiscal years 2014-2016 to support ECI program costs, the result is less IDEA Part C funding available to maintain base funding levels and serve eligible children in fiscal year 2017. Funding for this exceptional item is to maintain the number of children served in fiscal year 2016 in fiscal year 2017 in the ECI
program.”

What does this mean? It means that Texas has consistently underfunded the ECI program, relying on a finite amount of Federal funding instead. That funding is running out, creating a shortfall. If that shortfall is not covered, Texas will have to provide ECI services to fewer children.

The second special request is an additional $25,000,000 over the biennium to increase monthly caseload to over 30,000 by FY2017. DARS is projecting that even with their more stringent eligibility criteria the number of young Texans who qualify for ECI is going to increase pretty dramatically by FY17.

My take on the bottom line, DARS needs an almost fifty million additional dollars over the biennium to continue to offer services to young Texans who qualify under the current eligibility criteria. If they can’t get that through the Legislature, there will be another difficult round of system changes that involve a combination of more stringent eligibility criteria (so fewer children are being served) combined with more family cost share.

I have gone to two meetings in Austin over the past two weeks. On January 15th I was at the Early Childhood Intervention (ECI) Advisory Council meeting. On January 23rd I was at the Arc of Texas’ Government Affairs (GA) Committee meeting. Both are important meetings for different reasons and I thought I’d take a few minutes to discuss them both.

ECI Advisory Council meeting
The ECI meeting hinged around two things that are very important. The first was ECI’s annual performance report (APR) which is required by IDEA. ECI submits this report to the federal government each year. The report covers a number of federally mandated performance indicators. Two me, the two most important indicates are the child outcomes and the family outcomes:
• The child outcomes relate to both whether, as a result of ECI, children are making improvements and to whether they have caught up with their peers. Basically children are making improvements as a result of ECI, but the percentage of children who are functioning within age expectations as a result of ECI is declining.
• The family outcomes relate to whether ECI services help families to understand their rights, help families to effectively communicate their child’s needs, and whether it helps their children to develop and learn. In other words, this is where ECI asks the consumer about the effectiveness of the program. This indicator shows that families are very happy with the ECI services.
Why are child outcomes slipping in terms of functioning within age expectations? This one is complicated. Several years ago, ECI had to narrow the criteria of who is eligible for ECI services. This changed the mixture of the kids in the program, so the argument goes that this is having an impact on the ability to reach age expectations. This is a complicated argument because it seems that Texas is in the middle, nationally, in terms of eligibility for ECI services (i.e. some states have more rigid criteria, some have less rigid criteria) – but this isn’t something that I’m qualified to really quantify, so take this information with a grain of salt. According to the Early Childhood Technical Assistance Center (http://ectacenter.org/~pdfs/partc/part-c_sppapr_13.pdf#page=8) when compared nationally for the percentage of children reaching age expectations Texas is behind. However, examined another way Texas is one of 28-30 states (depends upon the outcome measure) that lost ground on this indicator over the last year.
With the family outcomes, this is powerful feedback and because of that I always get into a statistics debate in these meetings. DARS, in their 2014/2015 Legislative Appropriations Request, forecasted 25,187 children would be receiving ECI services each month in FY2012. The family outcome information is measured via a survey. Approximately 1200 families returned surveys. This number represents less than 5% of the people receiving ECI services. Now, this may be a statistically significant sample if you were writing a research paper, but it’s unclear how representative this really is of the entire state of Texas – which is always the source of my arguments on this one.
The second major issue from the ECI meeting was a piece of legislation from the 2013 legislative session, Senate Bill 1060. As background, a few years ago the state was unable to fund ECI at the level that was needed. As a result, ECI made three fundamental changes with profound consequences on the program. First, it narrowed eligibility. Second, it required providers to directly bill Medicaid. This reduced the administrative costs to DARS (i.e. it saved the state money) and required providers to develop a new skill set. Third, it required families to pay some of the costs of the services based upon their perceived ability to pay. This family cost share was expanded as a result of the appropriations that DARS received from the 2013 Legislature. SB1060 directs DARS to study the cost-effectiveness of the family cost share system and to implement rules to make it more cost-effective, as long as the changes don’t make receiving services cost-prohibitive. DARS will report on this to the Legislature by December 1st. In the legislation, cost-effectiveness is defined as: does the family cost share covering administrative expenses?
This seems fairly straightforward. Does the revenue brought in cover the costs? If not, what needs to be changed to make it so? The report that DARS is putting together, however, is a significant undertaking that is going to take a broad, comprehensive look at family cost share and administrative burden. DARS is also seeking input about the family cost share system and its impact on families, questions to consider:
• What needs to be included in this report?
• What information needs to be conveyed to the Legislature about family cost share?
• What should DARS be analyzing?
• How do we balance family cost-share with the desire to provide services and reality? The reality being that this is here to stay?
• Has family cost share made participating in ECI cost prohibitive?

Arc of Texas GA Committee meeting
I went to the Arc of Texas on the 23rd to attend the GA Committee meeting. For those of you that don’t know, the Arc of Texas is an advocacy organization on behalf of individuals with intellectual and developmental disabilities (IDD). They advocate on behalf of individuals with IDD, attempt to be effective with the legislative/appropriations process, train individuals with IDD to advocate on behalf of themselves, help educate the community about IDD issues and needs, and they attempt to keep everyone informed about issues that impact the IDD community.
The GA committee, to paraphrase its charge, has a duty to be very well educated about legislation, appropriations, policy, and matters impacting individuals with IDD and their families. Their task is to inform, educate, and guide the Arc of Texas and its board of directors in terms of how to act effectively particularly with the Legislature on behalf of individuals with IDD and their families.
This was the organizational meeting. The committee is made up of superstars. There are a lot of experienced, passionate, knowledgeable, hard-working people serving on this committee. The intent behind the committee was to review the past, chart out a structure for the future, and decide on some initial directions to focus on.
While the Legislature is not in session, things are not quiet and there is still work to be done. Senate Bill 7 is being implemented, legislative appropriation requests will need to be commented on beginning this summer, and legislation for the next session will be pre-filed beginning this fall. So this was a perfect time to meet with this committee.
The meeting began with reviewing the major pieces of legislation out of the last legislative session. Considerable time was spent discussing SB7. This took up the morning. This was important because you need to know where you’ve come from before you can decide where you are going.
The afternoon was spent looking forward. The committee developed three broad foci for the future, keep in mind that we may call these something totally different. The idea is to give us a place to start:
• Long-term services and supports: Medicaid waivers, Senate Bill 7, managed care, state supported living centers. It’s a big area.
• Education/Transition: ECI, K-12 and beyond, transition (which in Texas begins at 14). Again, another huge area.
• Employment/Transition/Transportation: Individuals with IDD want to find meaningful employment and it’s better for the state of Texas if they do. So this topic area covers employment, transitioning from school to being employed, and transportation. Transportation is huge because if you want to work, but are unable to drive yourself to work, then this is a barrier to being employable. Another huge area.
These three areas represent workgroups that the larger committee divided itself into. Some of us serve on one, some serve on all three. These workgroups are going to:
• Be researching these issues and developing recommendations for policy/legislative changes.
• Those recommendations will then be taken back to the full committee and will then become a draft of a legislative platform for the Arc of Texas.
• This draft platform will then go out to the various chapters and stakeholders for their input.
• After everyone’s input has been received, the GA committee will be developing a legislative platform for the Arc of Texas’ board of directors to vote on and then implement.

In other words, there is a lot of work to be done in a short period of time!

The Texas Comptroller has certified that the funds are available for the appropriations bills that came out of the 2013 Legislature. There is mixed news for people with intellectual and developmental disabilities and their families.
With regards to the Department of Assistive and Rehabilitative Services (DARS) and Early Childhood Intervention, there is good news and bad news for Early Childhood Intervention (ECI):
 ECI is seeing an almost 18% increase in its funding, from ~$270 million for the current biennium to ~$318 million for the upcoming one. Both respite and the administrative oversight of ECI are being funded at the same amounts as in the current biennium. In addition, the Legislature wants to see the number of hours of services per child per month to increase from an average of 2 hours to an average of 2.9 hours.
 The bad news is that the ECI appropriation has a rider. The rider says that anyone receiving ECI services who has a family income greater than 400% of the federal poverty level must pay 100% of the cost of the services.
It’s great that ECI funding is expanding and that the Legislature wants to see more hours of services per month per child. It will be interesting to hear DARS’ forecasts on how this will impact the number of children served. The rider is concerning and has significant long-term implications for both providers and the people that will be receiving ECI services. This will mean that some families will opt not to receive the services because they cannot afford it and others may be driven to private providers, which means that current ECI providers will have to learn how to be competitive with private providers.
With regards to the Department of Aging and Disability Services (DADS) and their long term services and supports appropriation, there is mixed news that reflects the shift to managed care that is being driven by Senate Bill 7. First, some programs are seeing a reduction in funding:
 Primary home care (~42% reduction): Provides non-skilled personal care services. Reduction is due to STAR+PLUS and this service will eventually be eliminated.
 Day Activity and Health Services (~67% reduction): Another casualty to STAR+PLUS.
 Community-Based Alternatives (~22% reduction): due to STAR+PLUS.
 ID Community Services (~7% reduction): Administrative expenses are being transferred elsewhere and some of the individuals receiving services are being transferred to the Texas Home Living Waiver.
 Promoting Independence Services (~5% reduction): Another casualty due to STAR+PLUS.
 Hospice (~5% reduction)
There are a number of programs seeing an increase in funding, including several waiver programs that are seeing a large increase in funding:
 Community Attendant Services (11% increase): Seems to be balancing out the reduction in primary home care.
 Home Community-Based Services (HCS) (15% increase)
 CLASS (10% increase)
 Deaf Blind Multiple Disabilities (38% increase)
 Medically Dependent Children (6% increase)
 Texas Home Living Waiver (63% increase)
 Nursing Facility Payments (4% increase)
 Medicare Skilled Nursing Facility (6.5% increase)
 Balancing Incentive Program: 14.7 million
 State Supported Living Centers (~2% increase)
It should be noted that none of the bills that sought to establish realignment committees for the State Supported Living Centers (SSLC), closure of the SSLCs, or bills of rights for people with intellectual and developmental disabilities passed. There are no riders directing DADS to close SSLCs, or explore closing SSLCs, only a rider to develop a ten year plan for the SSLCs.
The expansion of the waiver programs is great news. But the reality is that managed care is coming as a result of Senate Bill 7, so we’re going to be in uncharted territory soon. The fact that the Legislature will not move on the SSLCs is interesting.

Two identical bills have been filed in the Texas Legislature relating to Early Childhood Intervention (ECI).  The first is HB 1098 by Rep. Zerwas, the second is SB 1060 by Sen. Nelson.  These bills read like it is their desire to make ECI profitable.  As I read them, these bills have two parts. The first part (section 117.077) requires the Department of Assistive and Rehabilitative Servcies (DARS) to study the cost-effectiveness of the family cost share system of ECI.

As background, after the budget cuts in the last legislative session, DARS adopted a sliding family cost share for ECI based on family income.  This was one of their strategies to continue prvoding services in the face of the budget cuts.  The first part of this bill reads like it’s attempting to make ECI profitable (cost-effective means that family cost share revenue is greater than total administrative costs):
• DARS is required to collect data which lets them determine this information and evaluate the cost-effectiveness of the program.
• DARS is required to consider changes to make the program more cost-effective but may decline to make them if DARS does not feel that these changes will make the program more cost-effective.
• DARS is required to report on this by December 2014.

Now, this section gives DARS some wiggle room:
• “Total administrative costs” is not defined in the legislation. For example, is that the cost of DARS oversight? Or is it ECI provider expenses for providing the service (therapists, front office staff, case supervision, etc)? Or just partial expenses of providing the service (for example, only office staff but not therapists)? Etc.
• If DARS does not judge it possible to make the program profitable they do not have to implement the changes.

The second part (section 117.078) is a little more concerning and instructs DARS to consider implementing family cost share provisions based upon the family’s size and adjusted gross income with families in higher income brackets being required to pay more that those same families paid before this bill’s implementation. This family cost share is already in progress based upon family income, but I’m reading this as a requirement to increase those amounts. Now, the legislation instructs DARS “to consider” doing this, as opposed to saying that DARS must do this, so there’s some wiggle room. But the legislation represents the Legislature’s philosophy that families should be paying for more of these types of services.

The Legislature is seeking new ways to provide these services as well as the Medicaid services.  The idea being to control expenses and provide more services to more people.  In this legislation, the intent is to use the profits of the family cost share to provide more services to more children.  HB 1098 is being heard in the Human Services committee of the House on Tuesday, 3/12/13.

Today I spent the day in Austin, largely at the state capitol.  This was an interesting day as there were a number of things happening:

  • Task Force for Children with Special Needs meeting
  • Senate Bill 7 hearing
  • Visits with legislators

Task Force for Children with Special Needs:

The Task Force is established by legislative statute and is a state-agency driven entity.  It’s purpose is to develop a strategic plan to meet the needs of children with special needs and is meant to integrate all the Health and Human Services agencies as well as agencies like the Texas Education Agency.  I was appointed by the executive commissioner of the Health and Human Services Commission as a parent member.  As a parent, I don’t get to vote but I do get to offer plenty of input, sometimes more frankly than the agency staffers are used to.

This was a short meeting because of the Senate Bill 7 hearing.  Basically it was to brief us on the Task Force’s two big initiatives.  The first is a comprehensive website, geared towards families, of the services available to children with special needs.  It’s meant to be a parent-friendly umbrella website that is easy to navigate.  More than that, it will have videos, information on developmental milestones as well as programs/services available by age (i.e. help prompt parents for the things they don’t know to think about), location of programs/services, etc.  It is also meant to have a regional component to help direct the parent to resources in their area.  The Task Force implemented a state wide research effort using focus groups, phone calls, and surveys and now the design of the website is in progress (funding for everything has been secured or is in progress with the current Legislature).

The second initiative is a crisis prevention/intervention service that would incorporate multiple agencies.  This is in the beginning stages of planning but it’s very needed and a great idea.

Senate Bill 7 Hearing:

DADS conducted a hearing on Senate Bill 7 this morning that ran at the same time as the Task Force meeting.  I decided ultimately not to attend this as I felt I’d be more impactful visiting legislators at the capitol (more on this later).  I’ve written everybody about my thoughts about this bill and I think the decisions have already been made on this one…

Visits with Legislators:

I spent about four hours visiting legislators, staffers, and committees.  I visited with mine, Sen. Paxton (staff) and Rep. Sanford (both the representative and his staff).  In addition I visited with Rep. Carter (staff) from Dallas, Rep. Raymond (staff), Sen. Nelson (staff), and both the Senate Health and Human Services committee staff as well as the House Human Services staff.

Let me begin by stating that I didn’t make any appointments with anyone ahead of time.  While this is courteous, I did not want anyone to have a chance to prepare.  I also, intentionally, came dressed as a parent of a child with special needs as opposed to a lobbyist.  So I showed up in khakis with a tie, but no expensive suits.  In each office, I walked in and announced that I am the parent of a child with Down Syndrome and I’d like to talk to someone about legislation and appropriations.

To start with my legislators, I spent a great deal more time with them and their staff than anyone else.  I focused my discussions with them around the following:

  • Senate Bill 7
  • State Supported Living Centers
  • Balancing Incentive funds

I think SB7 is going to pass.  So I had several talking points on this bill.  It has great intentions – more services to more people at reduced cost to the state.    Having said that, the devil is in the details and the people pushing the bill don’t understand the details, which is critical in this circumstance.  First, there needs to be significant stakeholder support at all stages.  That means as invited testimony (after all, the parents and family members – not the state agencies, are the experts on this topic), voting members of system redesign committees, and at each stage of legislation and rulemaking.  Second, there needs to be an understanding that this is an incredibly complicated population and service delivery driven by assessments is going to miss a lot.  I made the point that this population requires medical care, dental care, many types of therapies, 24/7 care, employment care, housing, etc.  To illustrate the complexity, I used an example from the state supported living centers.  Back when the Department of Justice issued its findings about the old state schools, it used two specific examples as examples of a lack of oversight by the schools.  In one example, a state school resident had been eating latex gloves.  In another, a different resident was eating the stuffing from a chair.  I used these examples and explained that they are examples of how profoundly some individuals with intellectual and developmental disabilities are affected and how difficult it’s going to be to assess this and come up with services to prevent it.  I made these SB7 point with everyone and every committee that I visited with, with two exceptions that I’ll talk about in a minute.  In each case, the people I talked to had no idea it was like this.

Regarding the state supported living centers, I focused on two things.  First, if we are going to have them we should do it right – which means strong funding and appropriate staffing for fewer of them.  Second, Sen. Rodriguez has filled two bills (one is SB 729) on evaluating the SSLC’s and establishing a realignment commission for them.  I wanted my legislators to know that I support both bills.

The Federal Government is making available ‘Balancing Incentive” (BIP) funds for Medicaid programs.  My understanding is that this is intended to be seed money to kick start efficiencies and better service delivery.  So, for example, the website I spoke about earlier is going to be funded by BIP funding.  The problem is that both the House and Senate appropriations committees are sweeping more programs into this funding (because the state doesn’t have to pay for it).  This is a problem because the funds will go away, so any on-going program will lose funding once that happens.  This happened two sessions ago with Federal stimulus funding and ECI – ECI was ramped up and expanded with that funding, but after it went away it had to be cut back because the state would not make up the difference.  This is a concern with BIP funding.

I visited with Rep. Carter’s staff.  She is on the House’s appropriation’s committee for Article II (health and human services).  I had written each of them about the need to fully fund ECI, which they did.  She wrote me back, so I visited to say thank you.  I also put in my $0.02 about the BIP funding that I mentioned above with her staff.

Rep. Raymond is the chair of the House Human Services committee.  His office will either craft its own version of SB7 or receive the Senate version once the Senate passes it.  I spoke with his staff about the points I described above.  After meeting with me, they asked me to go talk to the Human Services committee staff about this, which I did.  This (the committee meeting) was one of the longer meetings that I was in today.

As the author of SB 7, I dropped by Sen. Nelson’s office.  Her office made it clear that they are not the ones listening to feedback about this bill and that I should go speak with the Senate Health and Human Services committee staff (which is located in another building).  I did this, and they let me know that the only person qualified to listen to feedback isn’t available – but I’m welcome to email (which I will).  I think it’s evident that the good senator is no longer desiring to hear feedback about what she set in motion from normal people.

I appreciate the time that everyone (with one exception) gave me.  I think I was able to make the points about the need for significant stakeholder involvement combined with an appreciation for how complex these matters are, while everyone has great intentions there’s a real lack of understanding about the things they are trying to change.  I’m also very happy because I have lots of contacts, who will be receiving my thoughts on these matters as the session progresses!

We’re about two weeks away from one of the filing deadlines for the 83rd Texas Legislature, so it’s a good time to review what’s going on.  We’ll spend the bulk of this blog covering legislation and trends.  Keep in mind that at this point some bills are being heard in committee, but none have been passed.  Just because legislation has been filed does not mean that it will amount to anything. 

 

Budget:

Unlike the 82nd Legislature, both the House and Senate bills provide for an increase in funding to DADS and DARS.  Now, the funding isn’t enough to reverse the cuts from the last session and are never enough, but at least this is going in the right direction.  DADS, DARS, and HHSC all have exceptional items to help improve long term services and supports and those are being heard and considered (some positively) by both the House and Senate. 

 

Regarding legislation, we’ll focus on several areas:

  • Education
  • Medicaid
  • State supported living centers (SSLC’s)
  • Miscellaneous

 

Education:

There are a number of bills that would lower the age where transition services begin to 14 and that would require schools to have a point person for answering transition-related questions.  This type of legislation has been filed in previous sessions.  In addition, there is legislation attempting to establish a school choice program for children in special education, one bill by Sen. Lucio that would require professional development with regards to working with children with special needs, and one concerning one by Rep. Ratliff that would allow for the establishment of disabled charter schools (this would seem to eliminate a child’s ability to receive an education with his/her non-disabled peers).

 

Medicaid:

If half of this legislation passes, this session will see a major change in Medicaid programs and long-term services and supports.  First, I’ve already blogged about Senate Bill 7 which would eventually transfer all the waiver programs over to managed care.  This looks like it is going to happen and the advocacy groups are torn between opposing it and recognizing its inevitability and seeking to get the best worst bill that they can.  Other bills address Medicaid fraud, requiring STAR+PLUS and managed care organizations to be subject to differing levels of review, some address long term services and supports, and others would tinker with the coverage that people receive.  As the parent of a child with a disability, I’m really concerned about this entire section and everyone else should be as well.

 

State Supported Living Centers:

By and large there are no major changes based upon legislation.  The Legislature has historically been reluctant to even address closing or consolidating the centers, as a result there is frequently legislation to provide band aid fixes.  Now, there’s one exception that really stands out.  Sen. Rodriguez filed SB729, which would seek to establish a SSLC closure and realignment commission (think about what happened to military bases in the 90’s).

 

Misc:

There are sunset review bills for health and human services agencies, bills that would seek to outsource the functions of those agencies, a lot of bills that deal with long-term service and support allowances, therapies, prescription drug benefits, licenses for facilities, and personal needs allowances.

 

I think a good summary of this session to date is that there is an intent to really change the waiver programs and shift them over to managed care.  The intent is to reduce/eliminate interest lists and strive for efficiency.

 

 

The Texas Legislature has released their budget bills, House Bill 1 and Senate Bill 1.  When passed, these bills will be the funding for state agencies in 2014 and 2015.    This information is important because it has an impact on the various state agencies to provide services.

The proposed budget for Early Childhood Intervention, administrated by the Department of Assistive and Rehabilitative Services, is mixed.  In the current biennium, ECI will receive $274,144,828 to provide services, provide respite services, and ensure the quality of ECI statewide.  This current biennium represented a sharp decrease in funding compared to the previous one.  As a result, DARS had to implement a number of changes to help contain costs while continuing to provide services.

These changes included implementing a family cost share.  In other words, families paid for a portion of their child’s ECI services according to a sliding scale based upon family income (families with more income paid more).  Another change was to require ECI providers to directly bill Medicaid to be reimbursed.  This saved DARS money because it meant that DARS no longer had to do this.  However, this was a skill set that many providers did not have and has led to challenging decisions such as: Do I hire a provider or someone knowledgeable about Medicaid billing?  Finally, DARS narrowed the criteria of who is eligible for ECI services, which meant that fewer children are receiving services today.

Now, this last change especially has had some ramifications.  By narrowing the eligibility, the make-up of the children receiving ECI services has changed.  This has resulted in their being more severely impacted by delays, requiring more services, increasing the cost of those services.   As a result, DARS is projecting that if funding for ECI remains flat over the 2014/2015 biennium, they will have to narrow eligibility even further.

In the current biennium, DARS is receiving approximately $274 million for ECI.  They asked for approximately $334 million, which took into account the state’s population increases, projected future demand, and the change in the make-up of children receiving those services.  Both HB1 and SB1 are recommending that ECI receive $297 million in funding, which represents an 8.5% increase over the current biennium.

While the increase in funding is a positive thing, it does come close to what DARS needs to continue offering services at the current eligibility level.  It is likely that if the budget passes as is, that DARS will have to narrow the eligibility in the upcoming biennium.

Now, neither budget bill is set in stone.  There will be lots of opportunities for input.  First, you can contact your representative and senator and provide feedback.  Second, there will be plenty of budget hearings over the next few months where written testimony and in-person testimony can be provided.  The budgets will go through a cycle of hearings, adjustments, and both the Senate and House versions will need to be reconciled before it goes to the Governor for his signature.

In previous postings I have discussed issues that have arisen as a result of funding constraints for Early Childhood Intervention (ECI) in Texas.  As a result of funding constraints, the state agency that oversees ECI (Department of Assistive and Rehabilitative Services, DARS) had to make changes to ECI which included:

  • Narrowing the eligibility of who qualifies for ECI
  • Implementing a family cost share so that parents pay for some of the services
  • Requiring ECI providers to directly bill Medicaid for reimbursement

 

These changes had unintended consequences.  Because eligibility was narrowed, it resulted in the children being admitted to the program needing greater services.  This means that ultimately as the population increases, the program will have to be narrowed even further (if funding remains static) due to this.

 

Texas is not the only state experiencing challenges with providing ECI to children and infants.  The IDEA Infant and Toddler Coordinators Association (www.ideainfanttoddler.org) does an annual survey of IDEA Part C (i.e. ECI) coordinators about implementation issues and challenges.   The 2011 survey is located here: www.ideainfanttoddler.org/pdf/2011_State_Challenges.pdf .  The survey results are sobering.

 

I’ll look at this report dealing with several matters:

  • Eligibility for ECI
  • Service delivery
  • Fiscal matters
  • Participation in Part C

 

Eligibility:

Texas narrowed the eligibility of infants and toddlers who qualify for ECI, as a result fewer children are admitted into ECI.  Of the 50 states and 3 territories surveyed:

  • 20 states require one of the following for eligibility for ECI: at least 25% delayed in two or more domains, 30% delay in one or more domains, 33% delay in one domain, 1.3 standard deviations in two domains, 1.5 standard deviations in one domain
  • 18 states require one of the following for eligibility for ECI: 40% delay in one domain, 50% delay in one domain, 1.5 standard deviations in two or more domains, 1.75 standard deviations in one domain, 2 standard deviations in one domain, 2 standard deviations in two or more domains.

 

In other words, 38 states are more restrictive than Texas in terms of eligibility criteria.  In addition, ten states made their eligibility criteria more restrictive over the last three years.  One made theirs broader.  Ten are changing their criteria this year.

 

Service Delivery:

Looking at all states, the number of direct services hours that were delivered, per child per month, has declined by approximately 22% from 2009 to 2011.  In 2011, the nationwide median for number of hours of delivered services, per child, per month, was 4.5 hours.

 

Fiscal Matters:

As a result of funding challenges:

  • 8 states have implemented family cost shares or increased those fees
  • 9 states have required the use of private insurance for ECI
  • 9 states have narrowed eligibility
  • 8 states have required prior approval when service hours exceed a specific amount
  • 13 states have reduced ECI provider reimbursement

 

21 states have conducted some type of study or planning process as a result of the fiscal situation.

 

In other words, like Texas, a lot of states are experiencing funding challenges with ECI.

 

Participation in Part C:

Worryingly, according to this survey, eight states are discussing or planning dropping out of Part C.  Most of this is due to the cost of the program and population growth (i.e. it’s not a sustainable program).

 

It’s a sobering look at the rest of the country and hopefully provides some perspective on what is happening in Texas currently.

 

Yesterday (10/10/12) I attended the Early Childhood Intervention (ECI) Advisory Committee quarterly meeting. There were several interesting items that came up in the meeting:
• Report on family outcomes
• Consequences to the system changed to ECI in Texas
• Providers of ECI in Texas

Family Outcomes
The Department of Assistive and Rehabilitative Services (DARS) ECI staff does an annual report to the federal Office of Special Education Programs. Among other things, ECI reports on three family outcome indicators:
1. How helpful has ECI been on helping families know their rights?
2. How helpful has ECI been for communicating their child’s needs?
3. How helpful has ECI been in helping the child to develop and learn?

Each indicator is made up of 6-8 questions. These indicators are measured via a survey that is conducted amongst half of the ECI providers in December.

For the fiscal year that just ended (FY2012), the three indicators declined relative to the year before, though they all met the targets that the state has set. Drilling down into the indicators, it appears that three concerns were responsible for this decline:
• Transition education from ECI to the next stage
• Education about the range of services available to the family and the child
• Helping children get along with others: in terms of behavior but also in terms of things like day care placement

There are two cautions about this survey and its results. First, the timing is important. This survey went out just as the system-wide changes to ECI were really beginning to kick in. It’s unclear our reflective these survey results are of the situation today, a year after the system-wide changes were implemented. Second, the sample size is incredibly small. These survey results are based on 943 responses. In December of 2011 there were 25,035 children enrolled in ECI. With the survey going out to half the programs, there are somewhere around 12,517 potential children in that population (although that is dependent on the size of the programs surveyed). 943 out of 12,517 represent a sample size of 7.5%. Here’s the problem: a sample size that is too small means you are unsure if the survey results adequately reflect the population. Normally when conducting surveys you figure out what type of sample size you need. When I asked about this, I got a deflecting-type of answer.

Consequences of System Changes
The system-wide changes to ECI (narrowing of eligibility, family cost share, provider direct billing of Medicaid, and measureable outcomes) have had effects on providers, families, and children. For the providers, they have been in an identity crisis and have had to gradually shift their focus away from families and more towards business, billing, and measuring/assessing outcomes.

For everyone else, the consequences of the system-wide changes have been complicated. First, by narrowing eligibility fewer children are being served. In FY2010 there were 32,101 children being served. In FY2012, there were 25,035. This is a 22% reduction. Second, by narrowing eligibility the mix of who is receiving ECI has changed. In 2010, 16% of those children were “atypical” in the sense that they were not developing at the “normal” rate. Today that group makes up 3% of the ECI population whereas there are a greater percentage of children with a medical diagnosis or developmental delays. This means that those individuals still receiving services require more intensive services. As a result, the average direct services per child per month has increased from 2.1 hours in FY2010 to 2.7 hours in FY2012 (a 29% increase). It is expected to eventually move up to 2.9. On the surface this sounds positive, but as the population of Texas increases and if funding stays static, it means that fewer children will be able to be served in future years.

Providers of ECI
Since FY2010, the number of ECI providers in Texas has declined from 58 to 51, or a 12% reduction. Of the seven providers that were lost, 3 were independent school districts and 2 were education service centers. In other words, 5/7 of the providers lost were related to the public school system. This is largely because as providing ECI has become more complicated in terms of narrowed eligibility, direct billing of Medicaid, and outcomes assessment the public school system is deciding that this is too difficult given that working with 0-3 year olds isn’t part of their purpose for being here.

The Department of Assistive and Rehabilitative Services (DARS) in Texas published its Legislative Appropriations Request (LAR) on its website yesterday.  To view this document in its entirety click here:   .  This is where the agency makes its request to the Legislature, Governor, and Legislative Budget Board for its funding for 2014 and 2015.  This will be followed by a hearing before those bodies on September 10, 2012 in Austin where DARS will present this request.  I’m going to write a little bit about the background behind this request, the consequences of the background, and discuss how the current request impacts Early Childhood Intervention (ECI).

First, as background ECI had its funding cut by 14% for 2012 and 2013 (the current biennium).  As a result, DARS had to make some tough decisions to continue to offer services with such a reduced budget.  These decisions were:

  1. Narrow the eligibility requirements of who gets ECI services.  This means that fewer kids are receiving services today.
  2. Implement a family cost share, which means that as a family’s income level increases they pay for a greater share of the ECI services that their child receives.
  3. Require ECI providers to directly bill Medicaid to be reimbursed.  This is was not a skill set that many of these providers possessed.

The effect of these cuts has been dramatic.  In 2011, 3.62% of children under the age of three were served by ECI.  This number will drop to 2.96% in 2014.  In 2011, the number of children enrolled in ECI declined by 6.1%.  This will decline by a further 17.1% in 2012 and is forecasted to be flat (i.e. zero growth) in 2014.  The DARS LAR has ECI services suffering a 12% reduction in funding from 2011 to 2014. 

There are a number of complications.  First, the population of Texas is increasing.  Just because of this the number of children needing ECI services will increase.  Second, while narrowing the eligibility decreased the number of children receiving ECI it also had another effect, it meant that those children receiving ECI were more significantly delayed and required more services.  The combination of these two mean that keeping funding flat (i.e. the proposed LAR) will result in another narrowing of eligibility because the current funds cannot fund the future demands even with the changes that have been put into place.

As a result of this, DARS has two exceptional items that they are requesting funding for with regards to ECI.  The first requests approximately $8 million in 2014 and $16.5 million from all funds to fund the anticipated growth in the number of children who will qualify for ECI even under the current narrowed eligibility criteria.  The second requests approximately $8.7 million in 2014 and $9.2 million in 2015 to maintain the level of service to children (this refers to hours/week) due to the fact that children with more severe delays (which is the result of narrowed eligibility criteria) require more services.

If ECI does not receive the exceptional item funding that it is requesting, then it will have to narrow the eligibility requirements still further. This will mean that fewer children with needs will receive services.  These needs won’t go away, they will be transferred to the public schools because they are not addressed early.  This may impact children’s success in school, their success in employment, and the amount of public assistance they are going to require in school and in their post-school lives.