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Understanding the New Fee for
Service System: An Overview for
Individuals and Families
New Jersey Department of Human Services
Division of Developmental Disabilities
October 21, 2014
Elizabeth M. Shea
Assistant Commissioner
Thomas Papa
Chief of Staff
Fee for Service Shift: Part of a Larger Reform Effort
Shifting to a Life Course model
Promoting full community participation
Moving from institutional to community-based
support
Moving to a Supportive Housing model
Creating consistency to ensure equity across the
system
Maximizing federal reimbursement to serve
more individuals
Establishing a two-waiver system
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What is a Fee for Service (FFS) System?
A change in the way providers are reimbursed
OLD
NEW: FFS
Annual contracts between
DDD and providers (payment
prior to service)
Providers submit claims for
payment after service
“Slot”-based/
“Program”-based
“Billable service unit” by
individual
Multiple rates for similar
services
Standard rates for
standardized services
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What is a Fee for Service (FFS) System?
In some cases, shift from contract-based
“programs” to combination of discreet services
FOR EXAMPLE:
Day Habilitation Services:
18 hours/week
Day Program
(Old Model)*
Prevocational Training:
6 hours/week
Speech Therapy:
1 hours/week
*Based on a 25 hour/week day program. PLEASE NOTE: FFS system reforms
include an increase in the maximum # of Day Habilitation service hours to 30
per week.
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Standardized Rates
Rate Study
Comprehensive rate study January 2013 – July 2014
Resulted in Final Rate Report and Rate Schedule
available at:
www.nj.gov/humanservices/ddd/programs/ffs_implementation.html
Standard Rates for Standard Services
Needs-based assessment tied to individual
Services tied to needs-based assessment
Rates tied to standardized services
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REMINDER:
FFS System is Built on a Medicaid Platform
Individual served must be enrolled on Medicaid
Enrolled on either the Supports Program or
Community Care Waiver (CCW)
Enrolled at the time of service delivery (Medicaid
eligibility must be maintained)
Transitioning to Fee for Service moves funding from
a “program” basis to each individual for each
discreet service
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REMINDER:
FFS System is Built on a Medicaid Platform
Provider must be an approved Medicaid/DDD
provider for each separate service
Must meet all qualifications for the service
Must produce all necessary documentation
Must complete the Combined Application
(Medicaid/DDD)
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REMINDER:
FFS System is Built on a Medicaid Platform
Service must be a Medicaid Waiver service
Community Care Waiver or Supports Program
(Comprehensive Waiver)
Become familiar with the service definitions
Setting must be Home and Community Based
Implications of CMS Final Rule?
Service must be documented in the Individual
Service Plan (ISP)
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Fee for Service Rate Schedule: Quick Reference Guide
Types of Rates
Single Unit, Single Person Rates – per person rate per
unit of service (Ex: Career Planning)
Tiered Rates- per person rate is determined by an
individual’s assigned tier level, documented in ISP
(Ex: Day Habilitation)
Stepped Rates – per person rate is determined by
actual staffing ratio (Ex: Physical Therapy)
Negotiated Rates – services with no standard rate
(Ex: Assistive Technology)
Rates still being analyzed – Supports Brokerage,
Transportation
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How do the Standard Rates Apply to Self Hires?
Some services in the FFS System may be
delivered by “self hires” – individuals chosen by,
and managed by, a consumer/family member as
opposed to a provider agency.
Self hires will use the same standard rate
schedule for each applicable service; however
the rate for self hires – like all other providers –
must cover all cost components (i.e. benefits,
employment taxes, administrative costs for the
fiscal intermediary, etc.).
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What Services will be Available in the FFS System?
In most cases, the same services individuals
receive today will be available, however:
The way providers are reimbursed is changing; and
“Programs” will have to be unbundled and
differentiated into discreet “services”
Familiarity with the available services is key to
understanding:
How your current services are potentially changing; and
What new service options may be available
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Services Available – Supports Program
 Assistive Technology (B)
 Environmental Modifications (B)
 Prevocational Training (B)
 Behavioral Management (B)
 Financial Management Services – FI (SP)
 Respite (B)
 Career Planning (B)
 Goods and Services (SP)
 Speech, Language and Hearing Therapy (B)
 Case Management (CCW)
 Individual Supports (CCW)
 Support Coordination (B)
 Cognitive Rehabilitation (SP)
 Interpreter Services (SP)
 Supported Employment – Individual (B)
 Community Based Supports (SP)
 Natural Supports Training (SP)
 Supported Employment – Small Group (B)
 Community Inclusion Services (SP)
 Occupational Therapy (B)
 Supports Brokerage (SP)
 Community Transition Services (CCW)
 Personal Emergency Response System (B)
 Transportation (B)
 Day Habilitation (B)
 Physical Therapy (B)
 Vehicle Modifications (B)
SP=Supports Program
CCW=Community Care Waiver
B=Both
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Services Available – Community Care Waiver*
 Assistive Technology (B)
 Environmental Modifications (B)
 Prevocational Training (B)
 Behavioral Management (B)
 Financial Management Services – FI (SP)
 Respite (B)
 Career Planning (B)
 Goods and Services (SP)
 Speech, Language and Hearing Therapy (B)
 Case Management (CCW)
 Individual Supports (CCW)
 Support Coordination (B)
 Cognitive Rehabilitation (SP)
 Interpreter Services (SP)
 Supported Employment – Individual (B)
 Community Based Supports (SP)
 Natural Supports Training (SP)
 Supported Employment – Small Group (B)
 Community Inclusion Services (SP)
 Occupational Therapy (B)
 Supports Brokerage (SP)
 Community Transition Services (CCW)
 Personal Emergency Response System (B)
 Transportation (B)
 Day Habilitation (B)
 Physical Therapy (B)
 Vehicle Modifications (B)
*DRAFT only, pending final CMS approval
SP=Supports Program
CCW=Community Care Waiver
B=Both
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Services Available – Employment
 Assistive Technology (B)
 Environmental Modifications (B)
 Prevocational Training (B)
 Behavioral Management (B)
 Financial Management Services – FI (SP)
 Respite (B)
 Career Planning (B)
 Goods and Services (SP)
 Speech, Language and Hearing Therapy (B)
 Case Management (CCW)
 Individual Supports (CCW)
 Support Coordination (B)
 Cognitive Rehabilitation (SP)
 Interpreter Services (SP)
 Supported Employment – Individual (B)
 Community Based Supports (SP)
 Natural Supports Training (SP)
 Supported Employment – Small Group (B)
 Community Inclusion Services (SP)
 Occupational Therapy (B)
 Supports Brokerage (SP)
 Community Transition Services (CCW)
 Personal Emergency Response System (B)
 Transportation (B)
 Day Habilitation (B)
 Physical Therapy (B)
 Vehicle Modifications (B)
SP=Supports Program
CCW=Community Care Waiver
B=Both
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Services Available – Day Services
 Assistive Technology (B)
 Environmental Modifications (B)
 Prevocational Training (B)
 Behavioral Management (B)
 Financial Management Services – FI (SP)
 Respite (B)
 Career Planning (B)
 Goods and Services (SP)
 Speech, Language and Hearing Therapy (B)
 Case Management (CCW)
 Individual Supports (CCW)
 Support Coordination (B)
 Cognitive Rehabilitation (SP)
 Interpreter Services (SP)
 Supported Employment – Individual (B)
 Community Based Supports (SP)
 Natural Supports Training (SP)
 Supported Employment – Small Group (B)
 Community Inclusion Services (SP)
 Occupational Therapy (B)
 Supports Brokerage (SP)
 Community Transition Services (CCW)
 Personal Emergency Response System (B)
 Transportation (B)
 Day Habilitation (B)
 Physical Therapy (B)
 Vehicle Modifications (B)
SP=Supports Program
CCW=Community Care Waiver
B=Both
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Services Available – Personal Care & Staff Supports
 Assistive Technology (B)
 Environmental Modifications (B)
 Prevocational Training (B)
 Behavioral Management (B)
 Financial Management Services – FI (SP)
 Respite (B)
 Career Planning (B)
 Goods and Services (SP)
 Speech, Language and Hearing Therapy (B)
 Case Management (CCW)
 Individual Supports (CCW)
 Support Coordination (B)
 Cognitive Rehabilitation (SP)
 Interpreter Services (SP)
 Supported Employment – Individual (B)
 Community Based Supports (SP)
 Natural Supports Training (SP)
 Supported Employment – Small Group (B)
 Community Inclusion Services (SP)
 Occupational Therapy (B)
 Supports Brokerage (SP)
 Community Transition Services (CCW)
 Personal Emergency Response System (B)
 Transportation (B)
 Day Habilitation (B)
 Physical Therapy (B)
 Vehicle Modifications (B)
SP=Supports Program
CCW=Community Care Waiver
B=Both
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Services Available – Therapies & Related
 Assistive Technology (B)
 Environmental Modifications (B)
 Prevocational Training (B)
 Behavioral Management (B)
 Financial Management Services – FI (SP)
 Respite (B)
 Career Planning (B)
 Goods and Services (SP)
 Speech, Language and Hearing Therapy (B)
 Case Management (CCW)
 Individual Supports (CCW)
 Support Coordination (B)
 Cognitive Rehabilitation (SP)
 Interpreter Services (SP)
 Supported Employment – Individual (B)
 Community Based Supports (SP)
 Natural Supports Training (SP)
 Supported Employment – Small Group (B)
 Community Inclusion Services (SP)
 Occupational Therapy (B)
 Supports Brokerage (SP)
 Community Transition Services (CCW)
 Personal Emergency Response System (B)
 Transportation (B)
 Day Habilitation (B)
 Physical Therapy (B)
 Vehicle Modifications (B)
SP=Supports Program
CCW=Community Care Waiver
B=Both
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Services Available – Care Coordination
 Assistive Technology (B)
 Environmental Modifications (B)
 Prevocational Training (B)
 Behavioral Management (B)
 Financial Management Services – FI (SP)
 Respite (B)
 Career Planning (B)
 Goods and Services (SP)
 Speech, Language and Hearing Therapy (B)
 Case Management (CCW)
 Individual Supports (CCW)
 Support Coordination (B)
 Cognitive Rehabilitation (SP)
 Interpreter Services (SP)
 Supported Employment – Individual (B)
 Community Based Supports (SP)
 Natural Supports Training (SP)
 Supported Employment – Small Group (B)
 Community Inclusion Services (SP)
 Occupational Therapy (B)
 Supports Brokerage (SP)
 Community Transition Services (CCW)
 Personal Emergency Response System (B)
 Transportation (B)
 Day Habilitation (B)
 Physical Therapy (B)
 Vehicle Modifications (B)
SP=Supports Program
CCW=Community Care Waiver
B=Both
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Services Available – Accessibility & Related
 Assistive Technology (B)
 Environmental Modifications (B)
 Prevocational Training (B)
 Behavioral Management (B)
 Financial Management Services – FI (SP)
 Respite (B)
 Career Planning (B)
 Goods and Services (SP)
 Speech, Language and Hearing Therapy (B)
 Case Management (CCW)
 Individual Supports (CCW)
 Support Coordination (B)
 Cognitive Rehabilitation (SP)
 Interpreter Services (SP)
 Supported Employment – Individual (B)
 Community Based Supports (SP)
 Natural Supports Training (SP)
 Supported Employment – Small Group (B)
 Community Inclusion Services (SP)
 Occupational Therapy (B)
 Supports Brokerage (SP)
 Community Transition Services (CCW)
 Personal Emergency Response System (B)
 Transportation (B)
 Day Habilitation (B)
 Physical Therapy (B)
 Vehicle Modifications (B)
SP=Supports Program
CCW=Community Care Waiver
B=Both
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What Does this Change Mean for Individuals
and Families?
Increased flexibility
Services billed in smaller units
Unbundling of transportation
Unbundling of programs
Increased choice
Enhanced services
More providers to choose from
Increased quality
Open, competitive market
Division’s enhanced quality monitoring (including
disenrollment of providers delivering sub-standard services)
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How will the new FFS System work?
NJ Comprehensive Assessment Tool (NJ CAT)
Support Coordination model for all participants
Individualized Service Plan (ISP)
Person Centered Planning Tool (PCPT)
Prior authorization of services
Provider claims and gets paid after service is rendered
Amended as needed throughout the year, re-done annually
Quality Monitoring
Provider qualifications and approval
Provider and individual outcome monitoring
Provider disenrollment if needed
Support Coordination quality monitoring
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Checklist: What Can Individuals/Families Do
to Prepare?
Ensure and maintain Medicaid eligibility
Become familiar with new services and draft
service definitions
www.nj.gov/humanservices/ddd/programs/ffs_implementation.html
Research Support Coordination
Boggs Center Guide – Selecting a Support
Coordination Agency: Making Choices, Becoming
Empowered
http://rwjms.rutgers.edu/boggscenter/projects/infopeopleandfamilies.html
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Checklist: What Can Individuals/Families Do
to Prepare?
Talk to your provider
What are their plans?
Will they continue to offer the same services?
Are they familiar with the new services and service
definitions?
Review/understand new Individualized Service
Plan (ISP)
Person Centered Planning Tool (PCPT)
Employment-related outcome
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Fee for Service Resources
FFS Implementation Timeline
Additional Frequently Asked Questions & Webinars
Fee for Service Implementation web page:
www.nj.gov/humanservices/ddd/programs/ffs_implementation.html
Fee for Service Helpdesk email:
DDD.FeeforService@dhs.state.nj.us
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Q&A
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