Waivers and Personal Care Assistance: Program
Overview, Rates, Workforce, and Change Initiatives
January 20, 2021
Natasha Merz, Director
Disability Services Division
01/14/2021 1
Agenda
• Overview of Long-term Services and Supports (LTSS) & Home &
Community-Based Services (HCBS)
• PCA overview & rates
• Workforce Challenges Facing the Direct Support Workforce
• Disability Waiver Overview & Rates
• Waiver Reimagine
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Home and Community Based Services (HCBS) Programs
• The term “Long Term Services and Supports” refers to the array of services
available to support people with disabilities and older adults, including nursing
facilities, intermediate care facilities for people with developmental disabilities
and hospitals.
• Home and community based services are a subset of Long Term Services and
Supports. They are cost effective alternatives to institutional care, and enable
people with disabilities and older adults to live, work and participate in
community life. They include:
• Medical Assistance (MA) state plan home and community based services
• Medical Assistance (MA) home and community-based service waivers
• Federally funded services, but not through Medical Assistance
• State and local funded supports and services
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Percentage of people receiving HCBS versus Institutional Care
01/14/2021 Minnesota Department of Human Services | mn.gov/dhs 4
MA state plan home and community based services
• Minnesota offers a comprehensive benefit set.
• People meeting financial and functional need eligibility criteria may
receive the service.
• These services include:
• Personal Care Assistance (PCA)
• Home Care Nursing
• Skilled Nurse and Home Health Aide visits
• These state plan services have set rates
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Creation of the HCBS Waivers
Why were Home and Community-
Based Service (HCBS) waivers created?
• Federal legislation allows Medicaid funds
to be used for services outside an
institution
• Encourage states to develop supports
that will help people participate in their
community.
01/14/2021 6Minnesota Department of Human Services | mn.gov/dhs
MA HCBS Waivers
• Home and Community Based Services through MA waiver programs
provide additional services that support a person when state plan services
alone do not meet a person’s assessed needs.
• Minnesota provides five HCBS waivers:
• Elderly Waiver (EW)
• Developmental Disabilities (DD) Waiver
• Community Access for Disability Inclusion (CADI) Waiver
• Community Alternative Care (CAC) Waiver
• Brain Injury (BI) Waiver
• Level of care as a requirement
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HCBS Programs (SFY 2019)
Program Average Monthly People Served Total Annual Cost of Services
Disability Waivers
48,475
$2.73 billion
Elderly Waiver & Alternative
Care
28,618
$477 million
State Plan Home Care
PCA: 34,037
Home Health Agencies: 2,592
Home Care Nursing: 784
$1.14 billion
1/19/2021 mn.gov/dhs 8
Source: Nov. 2020 Forecast
• Disability Waivers includes the Brain Injury (BI), Community Alternative Care (CAC), Community Alternatives for Disability Inclusion (CADI), and Developmental Disability (DD) Waivers
• Elderly Waiver includes both fee-for-service and managed care
• State Plan Home Care includes PCA paid through fee-for-service and managed care. Home Health Agency and Home Care Nursing includes fee-for-service information. There are some additional people
who receive services, such as skilled nursing visits, paid through managed care.
Personal Care Assistance (PCA) Overview & Rates
Minnesota Department of Human Services | mn.gov/dhs
01/14/2021 9
MA State plan Personal Care Assistance (PCA) rates
• State plan PCA services do not use framework formulas to set rates.
• Currently, the rate for a 15 minute unit of service is $4.45 (or $17.80/hour)
and does not include inflationary updates.
• 72.5% of the rate must go to direct support professional wages and benefits.
• PCA rates have been adjusted periodically through legislation.
• There is no automatic inflationary adjustment for increased costs
• Increases require legislative action
• Data shows that PCAs are the lowest paid workers in the HCBS
workforce.
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Average 15-minute unit rates
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Service Rate methodology Current 15-minute rate*
Chore services Flat $3.76
PCA (1:1) Flat $4.45
Homemaker Flat $4.61
Home health aide, extended (disability waivers) Flat $5.49
Individual Home Support without Training DWRS $6.89
Night supervision DWRS $7.54
Individualized home supports with training DWRS $10.86
Positive supports specialist DWRS $10.87
Employment support/exploration DWRS $11.26
Housing access coordination DWRS $12.35
People supported by PCA services
• The PCA program is the most diverse LTSS program in Minnesota. In
state fiscal year 2019, 54% of all PCA recipients where BIPOC.
01/14/2021 Minnesota Department of Human Services | mn.gov/dhs 12
BIPOC White
Total
Minnesota Population 21% 79%
Total HCBS Population
34% 61%
Disability Waiver Population
23% 75%
Homecare Population (PCA)
54% 40%
Direct Support Workforce Shortage
The Direct Support Workforce
• Supporting peoples’ community lives requires a dedicated workforce
across Minnesota.
• Having well-trained direct support professionals (DSPs) in place leads
to better outcomes and more consistent care.
• Access to services and supports are challenged by a workforce
shortage faced by states across the nation.
• Minnesota currently has about 135,000 DSPs and will need an
additional 68,000 is coming years to meet the anticipated demand.
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Direct support wages
• Nationally, approximately 45 percent of DSPs live in households
earning less than 200 percent of the federal poverty level.
• Many variables affect the wages and benefits paid to direct support
workers, including but not limited to:
• Payment rates for services
• Cost of benefits
• Other employer costs
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Hourly Wages by Service Type
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One driving factor behind direct support wages is the payment rate for
services. Within the HCBS services in Minnesota there is notable
variation in the payment rates, which has lead to variation in the wages
for workers as well.
Service Type
Median Wage Rate (per hour)
Home Health Aide
$13.50 $21.96 - 32.04
PCA
$12.00 $17.80
Waiver Day Services
$12.47 $39.24
Waiver Residential Services
$12.65 $34.80
Waiver Unit
-based Services $12.29 $27.54 - 53.85
Addressing the Workforce Crisis
• Through the guidance and action of the legislature, the Olmstead
subcabinet, and advocacy efforts, DHS has been able to engage in a
multi-prong approach to understanding and addressing the ongoing
direct support workforce crisis.
• These efforts have included new policy development, investments in
service rates, and new data collection efforts that will expand the
understanding of the workforce limitations.
• Olmstead workforce shortage work plan
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PCA Vacancies 2002-2020
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0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2019
2020
Personal Care Aide Vacancies,
2002 to 2020, Minnesota
Questions?
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Disability Waiver Rates System
Disability Waiver Rate System (DWRS)
• Roughly 80% of DD, CADI, CAC, and BI waiver expenditures are set by the
Disability Waiver Rate System (DWRS) frameworks.
• These statutory frameworks use direct support professional wages as the
basis for the overall rate.
• Other cost components in the rates include benefits, supervision, program support,
and administrative costs.
• Direct support wage assumptions in the frameworks vary from $12.27 to
$22.38/hour.
• Wage component set by analysis of statutorily-specified BLS SOC codes.
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DWRS Rate Methodology Overview
• The rate setting methodologies, or ‘frameworks’ for the disability
waivers are set in Minnesota statute.
• The frameworks are based on the cost of providing services collected
through historical cost surveys and ongoing state and national data
collection.
• Includes an automatic inflationary update every other year which
adjust:
• Direct Support wage values (based on Bureau of Labor Statistics values)
• Consumer Price index changes on material goods
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Calculating a DWRS Rate
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Continued evaluation and analysis
• DWRS continues to be evaluated and updated based on new data and analysis.
Historically, this evaluation has been done with available sources including
national data or one-time cost surveys.
• Beginning in 2021, all providers of DWRS services will begin reporting their
service costs as required reporting. This data collection will allow for Minnesota-
specific data to inform future decisions about DWRS. Reported data includes
• Administrative and Direct Care wages, benefits, and payroll taxes
• Service Facilities Costs, including all building and maintenance costs
• Transportation Costs, program and non-program related
• Program Administrative Costs
• General Administrative Costs
01/14/2021 Minnesota Department of Human Services | mn.gov/dhs 24
Waiver Reimagine project
What we’ve learned in recent years
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Waiver programs
are too complex
and difficult to
understand.
There is a lack of accessible and
understandable information.
Inconsistencies can
occur between
different lead
agencies (counties
and tribal nations).
People have limited
control and flexibility
over their services.
Minnesota Department of Human Services | mn.gov/dhs
How We’re Improving: Waiver Reimagine
Waiver Reimagine will improve the overall
disability home and community-based waiver system.
so that it’s more person-centered, easier to understand,
and simpler to navigate.
Common
service menu
across all waivers
Two waiver
system based on
where a persons
lives and not on
their diagnosis
A budget based
on a person’s
assessed needs
Increase flexibility
to self-direct
01/14/2021 27Minnesota Department of Human Services | mn.gov/dhs
Learn more about Waiver Reimagine
You can learn more by:
• Watching this short video introduction to Waiver Reimagine.
• Sharing the Waiver Reimagine introductory flyer (PDF)
• Reviewing the frequently asked questions (FAQ) page
• Subscribing to get DHS Disability Services Division eList
announcements.
• Emailing DHS at Waiver.Reimagine@state.mn.us with questions or
input about Waiver Reimagine.
01/14/2021 28Minnesota Department of Human Services | mn.gov/dhs
Thank you!
Natasha Merz, Director
Disability Services Division
01/14/2021 29Minnesota Department of Human Services | mn.gov/dhs
