Evaluating Aging and Disability Resource Center Contract Changes (Limited-Scope)

Introduction

Senator Rick Billinger requested this limited-scope audit, which was authorized by the Legislative Post Audit Committee at its March 24, 2025 meeting.

Objectives, Scope, & Methodology

Our audit objective was to answer the following question:

1. Why did KDADS change how it contracts for Aging and Disability Resource Center services?

The scope of our work included talking to officials from the Kansas Department for Aging and Disability Services (KDADS), Centers for Medicare and Medicaid Services (CMS), and Area Agencies on Aging. We also reviewed relevant federal and state statutes and supporting documentation to determine what factors led to the department’s decision to change the contract for Aging and Disability Resource Center services in 2024.

More specific details about the scope of our work and the methods we used are included throughout the report as appropriate.

Important Disclosures

We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. Overall, we believe the evidence obtained provides a reasonable basis for our findings and conclusions based on those audit objectives.

Our audit reports and podcasts are available on our website www.kslpa.gov.

KDADS officials told us they changed the Aging and Disability Resource Center (ADRC) service contract to mitigate the appearance of a potential conflict-of-interest and to address longstanding performance issues with the HCBS waiver assessments.

The Kansas Department for Aging and Disability Services (KDADS) oversees ADRC services to help older adults and people with disabilities.

• Federal law (the Older Americans Act) requires states to have Aging and Disability Resource Centers (ADRCs) that provide certain services. However, it gives states flexibility to decide how they want to structure and implement the ADRC system and services. KDADS is the state agency that oversees the ADRC services in Kansas.

• In Kansas, ADRC services are for Kansans who are aging or have disabilities and need long-term services and supports to continue living in their communities. The ADRCs provide information, referrals, and assistance through a statewide call center. They also provide counseling services such as one-on-one assistance for a variety of needs, access to a database of service providers like transportation and nursing facilities, and referrals for nursing home pre-admission assessments.
  
• Until 2024, ADRC services also included functional assessments for Medicaid Home and Community Based Services (HCBS) waivers. Medicaid HCBS waivers allow states to provide services to individuals living in the community instead of institutions like nursing homes.
  • The functional assessments performed include brain injury (BI), physical disability (PD), and frail elderly (FE) waivers. A functional assessment is a tool used by states and providers that collects information on people applying for and participating in HCBS services.
  • Functional assessments determine the level-of-care eligibility and are the basis for a person-centered plan, which focuses on an individual’s needs and goals. The level-of-care eligibility determines what kind of services and which setting (nursing home, hospital, or intermediate care facility) the individual will need.
    

Until 2024, KDADS contracted with Area Agencies on Aging (AAAs) to provide ADRC services.

• Kansas has 11 AAAs. Each AAA is either a unit of county government or a private not-for-profit corporation. The AAAs receive federal, state, and local funding to provide a wide array of services that fall into 2 main categories.
  • First, the AAAs provide services to older adults and their caregivers throughout the state. For example, they provide information and resources about home and community-based services and help older individuals and their caregivers develop support networks in their communities. The AAAs also do things like provide nutrition services through home delivered meals and coordination of community-based services with local providers. This includes helping eligible individuals apply for Medicaid services. AAAs have aging services contracts with KDADS to provide these services.
  • Second, the AAAs provided ADRC services from 2012 until June 2025. Each of the 11 AAAs acted as a local ADRC. This includes statewide call center services, counseling for long-term care and support services, and 3 select Medicaid waiver assessments. AAAs had a separate contract with KDADS to provide these ADRC services.

• Nationally, it is not uncommon for AAAs to offer ADRC services. According to a 2022 survey by the national association of AAAs, 65% of the AAAs that responded to the survey provided ADRC services.

In 2024, KDADS split the one AAA contract for ADRC services into 2 contracts—one for the HCBS assessment services and one for the remaining ADRC services.

• KDADS first contracted with AAAs to provide ADRC services in 2012. One component of the contract was for HCBS waiver assessments. This included assessments for brain injury, physical disability, and frail elderly Medicaid waivers. KDADS renewed the contract over time. The other portion of the contract covered the other ADRC services such as providing information, referrals, and counseling for long-term care and support services. Its most recent contract with AAAs for ADRC services ended June 30, 2025.

• Before the contract expired, KDADS officials began the process of splitting the ADRC services contract into two separate contracts.
  • In August 2024, KDADS split the HCBS waiver assessment portion of the contract into a separate contract and issued a request for proposals (RFP). The contract is solely for an organization to provide functional assessments for brain injury, physical disability, and frail elderly Medicaid waivers. KDADS awarded the HCBS assessment contract to Maximus US Services Inc. The contract began January 26, 2025 and ends June 30, 2028.
  • In August 2024, KDADS also issued a separate RFP for the remaining ADRC services such as providing information, referrals, and counseling for long-term care and support services. The contract contains the same ADRC services as the previous contract with AAAs except for the HCBS functional assessments. KDADS awarded a contract for this portion of ADRC services to Liberty Healthcare Corporation. The contract began January 1, 2025 and ends June 30, 2028.

• The 6-month overlap between the end of the ADRC services contract with the AAAs and the start of the 2 new contracts was to allow the new providers time to hire staff and prepare to offer the services.

• Figure 1 shows examples of the services offered and the providers of the services for the contracts before and after the change. As the figure shows, the AAAs used to provide ADRC and aging services. Now, the AAAs still provide aging services, but the ADRC services have been split into 2 contracts with 2 different entities

KDADS officials told us they changed the ADRC services contract to mitigate the appearance of a conflict-of-interest and to address longstanding performance issues with HCBS waiver assessments.

• CMS officials told us they did not require KDADS to change the ADRC services contract. KDADS officials told us they wanted to change it for two primary reasons.

• First, KDADS officials said they had concerns with AAAs providing services like nutrition services and options counseling while also providing HCBS waiver assessments. They were concerned that situation could potentially be perceived by the federal government as a conflict-of-interest. They said changing the contract is a precautionary measure to help ensure they do not violate the federal government’s conflict-of-interest guidelines.
  • Centers for Medicare and Medicaid Services (CMS) requirements prohibit an entity providing case management or developing an individual’s service plan from also providing home and community-based services (unless CMS approves an exception). The requirements are intended to prevent self-referral.
  • AAAs did not develop service plans or manage individuals’ cases, but KDADS officials were concerned that having AAAs complete HCBS waiver assessments while also providing certain other services could be perceived as creating this scenario. KDADS officials told us they reviewed other states’ practices to identify options for addressing their concerns. During this review, KDADS learned the federal government does not require ADRC services and HCBS waiver assessments to be paired.
  • KDADS officials said separating the two portions of the contract should ensure there is no conflict. They also think it shows the federal government that Kansas is serious about eliminating perceived conflicts.
  • LPA did not independently assess whether the previous contract for ADRC services was a violation of conflict-of-interest.

• Second, KDADS officials said that splitting the contract should help address longstanding timeliness issues with the HCBS waiver assessments completed by the AAAs.
  • CMS requires HCBS waiver assessments to be within 12 months of the previous assessments for 86% of their clients and KDADS must work to remediate any measures that are below 100%.
  • According to KDADS’ performance measures, the AAAs did not complete timely HCBS waiver assessments since 2013. They completed HCBS waiver assessments within 12 months for 39% to 84% of the clients KDADS reviewed (it varies by year and by waiver). Kansas is on a quality improvement plan with CMS due to the state’s performance being below the minimum threshold.
  • KDADS officials said separating the two portions of the contract will allow one entity to focus solely on assessments. They told us this should create efficiencies to help address timeliness issues.

• KDADS officials told us they didn’t consider other options for addressing their concerns. However, they said they had several internal meetings before deciding to split the ADRC services contract.

The AAAs bid on 1 of the new contracts, but did not receive the award.

• KDADS officials told us they advised the AAAs to bid on both new ADRC services contracts to increase their chances of receiving a contract. However, officials told us they would not have awarded both contracts to one entity due to their concerns about a perceived conflict of interest.

• The AAAs submitted a bid for the HCBS waiver assessment contract but did not win the contract. KDADS officials told us there were 3 bids received for the HCBS contract. KDADS first reviewed the narrative of the proposal and ranked the bids for the HCBS contract based on how the plan addresses the RFP. After the initial ranking KDADS officials said they looked at the cost of each bid and factored that into the decision.

• Due to technical issues the AAAs didn’t submit a bid on time for the other ADRC services contract. KDADS officials told us the Department of Administration received the AAAs’ bid for the ADRC services contract after the deadline. KDADS received only 1 bid for the ADRC services contract.

• As shown in Figure 1, the AAAs have aging services contracts to provide other services that are not part of the ADRC services. This includes in-home services for older adults, support services for their caregivers, and nutrition services among others.

Recommendations

We did not make any recommendations for this audit.

Agency Response

On June 12, 2025 we provided the draft audit report to the Kansas Department for Aging and Disability Services (KDADS) and Kansas Association of Area Agencies on Aging and Disabilities.

Their responses are below. Agency officials generally agreed with our findings and conclusions.

KDADS Response

June 20th, 2025

Jonathan Jones, Auditor

Kansas Legislative Division of Post Audit

800 SW Jackson Street, Suite 1200

Topeka, KS 66612

Dear Mr. Jones:

On behalf of the Kansas Department for Aging and Disability Services (KDADS), I want to thank you and your team for conducting the limited-scope performance audit titled Evaluating Aging and Disability Resource Center Contract Changes. We appreciate the time, professionalism, and diligence your office brought to this important review.

KDADS takes seriously its responsibility to ensure transparency, integrity, and fairness in all procurement activities. We believe that all required procurement procedures were followed in accordance with applicable state guidelines throughout the Aging and Disability Resource Center (ADRC) contract process. The procurement was conducted with the intent to ensure open competition, and it is our view that the Area Agencies on Aging (AAAs) were afforded a fair and equitable opportunity to participate and submit bids.

We remain committed to collaborating with stakeholders across the aging and disability network to ensure high-quality, accessible services for all Kansans. We appreciate Legislative Post Audit’s role in supporting accountability and continuous improvement in public service.

Thank you again for your thorough work and for the opportunity to respond.

Sincerely,

Andrew Brown

Deputy Secretary for Programs

Kansas Department for Aging and Disability Services

Kansas Association of Area Agencies on Aging and Disabilities Response

June 23, 2025

Kansas Legislative Division of Post Audit

800 SW Jackson St.

Topeka, KS, 66612

Attn: Jonathan Jones

[email protected]

Re: Report Number: L-25-015

Thank you for the opportunity to provide a response to the limited-scope audit, Report Number: L-25-015. On behalf of the contractor, SouthWest Kansas Area Agencies on Aging, and the subcontracting ten (10) Area Agencies on Aging, the Kansas Association of Area Agencies on Aging (k4ad) provides the following responses.

Under the Older Americans Act, the Area Agencies on Aging fulfill a broad scope of responsibility to assist older adults and caregivers with securing an equal opportunity to the full and free enjoyment of their communities. The Act mandates each Area Agency on Aging provide: 1) Access to services (Transportation, outreach and public education, information and assistance/referral, legal, and case management services; 2) Home and community-based services (Homemaker and in-home care aides, visiting and telephone reassurance, chore maintenance, family caregiver support); 3) Nutrition Services (Congregate and Home-Delivered Meals, Nutrition Counseling and Education); 4) Disease Prevention and Health Promotion (evidence-based programming, including: Tai-Chi, Wheelchair Yoga, Matter of Balance, etc., and Chronic Disease Self-Management (Diabetes Counseling, etc.); and 5) Vulnerable Elder Rights (Protection from guardianship, Long-Term Care Ombudsman, Prevention of Elder Abuse, Neglect, and Exploitation). Each Area Agency on Aging is unique to their planning service area and the needs of their communities.

Since 2012 (after the pilot project, which started in 2008, was completed), the Aging and Disability Resource Center increased the visibility of the Area Agencies on Aging and strengthened the No Wrong Door model of service coordination to increase access to community-based services, regardless of the funding source. When the Act was reauthorized in 2020, Congress removed barriers within the aging network to increase business acumen and support capacity building.

KDADS officials failed to communicate to the contractor or subcontracting entities that an “appearance of a conflict-of-interest” existed until November 25, 2024, during testimony before the Kansas Legislative Budget Committee. We raise substantial concerns regarding the inconsistency of the testimony as “CMS officials [stated to the LPA that] they did not require KDADS to change the ADRC services contract.” If a concern was not voiced by CMS, a federal entity, how could there be a perception “by the federal government” that there “could potentially be a conflict-of-interest” when case management, development of the service plan, or direct services for the HCBS population are not provided by the Area Agencies on Aging?

Without an essential technical analysis or stakeholder input, potential harm to the aging network increases. These tools help identify risks, alternative strategies; and effectively manage change that would otherwise cause confusion and waste resources. Although KDADS “learned the federal government does not require ADRC services and HCBS waiver assessments to be paired,” the report does not reference those States where Area Agencies on Aging provide Options Counseling, Information Referral and Assistance (call center), Intake, Functional Eligibility Assessments for HCBS populations under one contract.

KDADS “officials said they had concerns with AAAs providing services like nutrition services and options counseling while also providing HCBS waiver assessments.” This expands the State’s definition of the COI rule, in conflict with the Older Americans Act. If this is a valid concern, this severely restricts the enterprise capability of establishing private pay contracts and commercial contracts that enhance the menu of services that complement, not divert from, Older Americans Act services, as allowed under Section 212. As policymakers and the health care sector have become increasingly aware of the negative impact that unmet social needs have on health, health care payers and providers are looking to improve care and outcomes by contracting with AAAs to provide social care services. Sections 212 and 306(g) highlight the importance of leveraging existing knowledge, expertise, and relationships to expand the reach of the aging services network. Additionally, a secondary reason that CMS recommends an analysis to determine if there was a potential conflict-of-interest, would be to protect the interests of the State and customers, and to ensure the alternative does not impede access to HCBS.

The “splitting [of] the contract should help address longstanding timeliness issues with the HCBS waiver assessments completed by the AAA.” Kansas is on a quality improvement plan with CMS specifically related to CMS Form 372, which requires KDADS to report on the State’s Medicaid long-term services and supports. The quality improvement plan references the Level of Care (LOC) and specifies “the state demonstrates that it implements the processes and instrument(s) specified in its approved waiver for evaluating/reevaluating an applicant’s/waiver participant’s waiver eligibility consistent with care provided in a hospital, NF, or ICF/ID-DD.” The Area Agencies on Aging perform the assessments related to home and community-based services in lieu of “care provided in a hospital or nursing facility.” However, CMS identified the issue as an ineffective process and missing data from Form 372 for corrective action, not timeliness issues.

The contractor agrees that reassessments are not always conducted timely. To remediate this issue, the contractor made several requests to KDADS officials to provide statewide data to implement a robust quality improvement program (QIP) to identify performance issues and make recommendations to processes that would increase efficiencies. Each request was denied for various reasons and an alternative of providing a Quarterly Reassessment (Fallout) Listing was agreeable. However, the reports were inconsistent and unreliable, as KAMIS is not a reliable management information system. The ADRC contract with SouthWest Kansas Area Agency on Aging requires the use of KAMIS for the annual reassessment lists. Additionally, the HCBS Brain Injury, Frail Elderly, and Physically Disabled waiver require the use of the State’s management information system for authorization to perform annual reassessments. No contractor should be held responsible for the State’s ineffective and inefficient processes or management information system.

A recent KAMIS Reassessment (Fallout) Listing reported 64 expired reassessments. After verifying eligibility in both KDADS and KDHE systems, only 8 (12%) individuals qualified for a reassessment since they were not Medicaid eligible during their reassessment month. Without financial eligibility, a reassessment is unallowable, and ensures state resources are not wasted. Another example is that a listing containing 1057 “past due” reassessments had more than 406 (38%) records that should have been closed.

For these reasons, the Kansas Association of Area Agencies on Aging and Disabilities consistently advocated for an effective management information system that would provide accurate and reliable data to effectively manage the Aging and Disability Resource Center (ADRC). To assist with this important component of contract and grant management, the Kansas Association of Area Agencies on Aging and Disabilities (k4ad) advocated for appropriations ($1 million) in the SFY24 budget to convene a management information system (MIS) steering committee of expert internal and external stakeholders that will analyze KAMIS system functions, measure performance, and generate reports and dashboards to develop a logical, phased implementation schedule required to maximize the value and performance of a management information system to maintain and report accurate data, including interface capability with KDHE systems managing Medicaid, and make recommendations to implement an optimal, functional management information system. Although the request was appropriated, the funds remain unspent.

We focus on the separation of services for 3 primarily reasons:

1. The No Wrong Door has been splintered and will substantially change how older adults, individuals with disabilities, and caregivers access long-term supports and services.

2. KDADS officials are holding the Area Agencies on Aging accountable for the State’s inefficient management information system and ineffective processes.

3. Stakeholders were not offered the opportunity to provide public comment, yet the separation of the services is a substantial modification of how customers will access the waivers.

We appreciate your time and effort to determine the reason why KDADS separated the Aging and Disability Resource Center into two separate contracts. Your report has provided valuable insights for the Area Agencies on Aging to continue serving Kansans so they can age well and age in place.

Respectfully,

Leslie A. Anderson

Executive Director

Appendix A – Cited References

This appendix lists the major publication we relied on for this report.

1. More Older Adults, More Complex Needs: Trends and New Directions from the National Survey of Area Agencies on Aging (2023). USAging.