1. Implementing Self-directed Services Under MLTSS September 10, 2014 3:00 – 4:30 pm EDT

2. Susan Flanagan Principal Westchester Consulting Group Suzanne Crisp Director of Program Design & Implementation NRCPDS

3. Purpose of Webinar
Provide an overview of implementing self-directed services under a managed long-term services and supports (MLTSS) system.
Discuss the challenges and lessons learned, promising practices and strategies for successful implementation and monitoring. 3

4. Purpose of Webinar (cont’d)
Provide opportunities for participants to:
Talk to each other!!
Hear directly from a State agency representative about challenges and successful strategies in implementing self-directed services under MLTSS.
Learn about available resources.
Share and discuss ideas for adopting and/or adapting successful strategies for implementation and monitoring services and MCEs’ performance. 4

5. Learning Objectives Participants will understand the:
- Key components of self-directed services and the MLTSS delivery model,
- States that have implemented and monitored the provision of self-directed services under MLTSS, and how one State accomplished this, and
- Benefits, challenges, lessons learned and successful strategies for implementing self-directed services under MLTSS. 5

6. Who is on the call today? 6

7. What is Self Direction?
Self Direction (also known as consumer or participant direction)
Is a HCBS delivery model where individuals and their representatives, when applicable, have decision-making authority and take direct responsibility for managing their services with the assistance of self-directed supports.
- Represents a paradigm shift in HCBS delivery – transferring decision-making and managerial authority from providers to individuals and families while providing them with supports. 7

8. What are Self-directed Services?
Promote choice and control for individuals and families over their LTSS and the direct service workers who provide them.
In 2013, the NRCPDS survey of participant-directed service programs identified 269 programs operating in 50 states serving ~ 840,000 people 8

9. What are Self-directed Services?(cont’d)
They liberate a nontraditional direct service workforce of relatives and friends.
- Many take advantage of the opportunity to hire relatives (i.e., 50 percent of participants in the RWJ Cash and Counseling Demonstration (Mahoney, 2005) and 72 percent of CA IHHS Program participants receiving Medicaid State Plan personal care services (CA DHHS, 2013)). 9

10. Options for Providing Self-directed Services Under Medicaid
§1915(i) HCBS SPA
§1915(k) Community First Choice SPA
§1915(j) Self-directed PAS SPA (overlies other authorities)
§1915(c) HCBS and §1115 Demonstration Waivers 10

11. Common Characteristics of Self-directed Services
Person-centered planning process
Flexible service plan
Individual budget
Information & assistance (I&A) in support of self-direction
Financial management services (FMS)
Quality assurance and improvement 11

12. Key Domains of Self-directed Services
Degree of flexibility
Employer Authority. Is the individual/ representative allowed to act as a common law or joint employer of his/her direct service workers and manage or actively participate in performing employer tasks?
Budget Authority. Is the individual/representative allowed to develop and manage an individual budget of their LTSS and purchase individual-directed goods and services? 12

13. Key Domains of Self-directed Services (cont’d)
Supports available
- Information and Assistance (I&A)
- Financial Management Services (FMS)
Self-directed service implementation
- Developing FMS and I&A standards
- Developing performance-based contracts and/or
Medicaid provider certification requirements 13

14. Key Domains of Self-directed Services (cont’d)
Ensuring self-directed service program is in
compliance with 9/17/13 DoL FLSA Rule for
Companionship and Live-in Exemptions to
Domestic Service including determining
state’s status as a third party joint-employer
- Implementing FMS & I&A Readiness Review 14

15. Key Domains of Self-directed Services (cont’d)
Monitoring quality of:
Self-directed service delivery
FMS and I&A performance 15

16. Key Domains of Self-directed Services (cont’d)
- Tools
Agreed upon procedures reviews
Reporting
Benchmarks
Assessing user experience and satisfaction (surveys) 16

17. Processing and Discussion
What is your biggest insight about what you just heard? 17

18. What is Managed LTSS?
Delivery system where States contract with managed care entities (MCE) defined at 42 CFR to provide LTSS generally through a capitated monthly per member payment
MCE manages LTSS through degrees of financial risks for members
May be HCBS and/or institutional care 18

19. Why Do States Implement MLTSS Delivery Systems?
Looking for health care cost controls
Moving towards integrated, coordinated care – reduce fragmentation in service delivery
Focus on transition planning
Enrollees transitioning from institutions to HCBS 19

20. Options for Implementing MLTSS
Medicaid Authorities Vary
§1915(b)/(c) (FL, WI, MI, MN - SCP, NM*)
§1115(a) (AZ, HI, NM*, TN & TX)
§1915(a)/(c) (MA)(MN SHO)
§1932(a) (WA)
§1115(a)/1915(c) – (KS)
*NM transitioned its §1915b/c to §1115(a) authority.
*MN is transitioning its §1915(b)/(c) to §1115(a) authority. 20

21. CMS’ Position on Provision of Self-directed Services Under MLTSS
CMS supports self-direction (SD) in both fee-for-service & managed care service delivery systems implemented under §1115(a) and
§1915(b) (Most recently published in May 2013)
States that offer self-directed services … are expected to continue….
States that do not currently offer self-directed services… should consider providing the opportunity…within a MLTSS program. 21

22. 21 States Had MLTSS Programs as of May 2014, Up From 8 in 2004 (Truven Health Analytics)
MLTSS implemented
MLTSS implemented 2005-May 2014 22

23. How Is Self Direction Beneficial to MCEs?
Positive response to advocates and member requests for more flexibility
Use of service coordination and efficiency strategies have the potential to provide more services for the same dollars 23

24. Selected Studies on Implementing Self-directed Services Under MLTSS
ASPE -Truven Five State Study (2013)
AZ, MA, NM, TN & TX
Mathematica/CMS Report: Selected Provisions from Integrated Care RFPs and Contracts: Participant Direction (2014)
ASPE Study States and FL, HI, KS, MI, MN, WA & WI 24

25. Study Methodology Both studies use a qualitative case study method
ASPE-Truven Five State Study
Reviewed
Request for Proposals
Contracts
Policy & Procedures 25

26. Study Methodology (cont’d)
Interviewed
State Officials
Managed Care Entities (MCE) Administration & Service Coordinators
FMS Agencies
Advocacy Groups
Mathematica Study
Reviewed
Request for Proposals
Contracts
Policy & Procedures 26

27. Findings from Selected Studies
Findings Include:
Number of individuals who self-direct in MCEs – 77,500
All States reviewed include people with disabilities and elders
Most “carve-out” intellectual and developmental disabilities
All but one State required the MCE to introduce the self direction option
All but one State include the essential elements of self direction in their contract with the MCE 27

28. Findings from Selected Studies (cont’d)
Wide variation in:
Number of members enrolled
Training for MCE service coordinators
Quality assurance/improvement, oversight, and monitoring
Some States rely on contracts to manage self-directed services; others use policy & procedures
Four States offer employer and budget authority
Two States have recently dropped budget authority
In one State budget authority is limited to employment related issues 28

29. Findings from Selected Studies (cont’d)
- Information & Assistance
Internal to MCE or subcontracted
One State created a new function to manage the day-to-day supports provided to members and coordinate activity with MCE case manager and FMS
Training is conducted by the MCE often with help from the Aging and Disability Network 29

30. Findings from Selected Studies (cont’d)
- Most States require their final approval of FMS vendors used
States may delegate the selection and legal arrangement between the MCE and FMS
States may arrange for FMS vendors directly
States may execute the legal agreement or enter into a 3-way contract between the State, the MCE and the FMS 30

31. Findings from Selected Studies (cont’d)
- The number of FMS vendors used by a State varied
from 1 to 400
- Five States use Vendor F/EA FMS
- Six States use both Vendor F/EA FMS and Agency
with Choice
- None of the States use the Government F/EA FMS
- Growing trend to offer both FMS models within a
State 31

32. Observations
States play a major role in implementing self-direction and MLTSS.
Commitment to self direction is related to the State’s expectations and guidance.
Member introduction & orientation, and on-going support of self direction can be time-consuming for service coordinators and often is conducted in an inconsistent manner. 32

33. Observations (cont’d)
How self direction is presented is critical to a member’s understanding and willingness to use this service delivery option.
“Less is more” when implementing FMS so State can monitor performance of FMS vendors in an effective and timely manner. 33

34. Observations (cont’d)
It is unclear how committed MCEs are and their level of understanding of self direction.
Standardized training for MCE service coordinators is key for successful recruitment and retention of members using self direction. 34

35. Observations (cont’d)
Specific language/standards for self direction included in State policies and procedures may be more effective in implementing self direction under MLTSS than embedding self direction language in administrative contracts with MCEs 35

36. Processing and Discussion
What is your biggest insight about what you just heard? 36

37. State Successful Strategy Presenter
Michelle Morse Jernigan, Deputy, LTSS Quality Administration, TN Dept of Finance and Administration, Bureau of TennCare
(615) 37

38. What Did We Do? Tennessee implemented managed care in1994.
Mandate that all TennCare members enroll in managed care
Coordinated all physical and behavioral health needs
In 2010, the State implemented MLTSS - CHOICES 38

39. What Did We Do? (cont’d) Implementation of CHOICES “Carved in” LTSS
Nursing facility care and HCBS
Elders age 65+ and adults age 21+ with physical disability
Added Community Based Residential Alternatives to HCBS package
Added consumer direction option 39

40. What Did We Do? (cont’d) Consumer Directed Option
Vendor Fiscal/Employer Agent (VF/EA) Financial Management Service (FMS) model used
1,177 participants (as of 5/1/14)
1,459 consumer-directed workers
Total CHOICES enrollment (as of 5/1/14)
NF = 18,170 (59%)
HCBS = 12,740 (41%)
~ 9% of total HCBS members self-directing 40

41. Challenges & Lessons Learned
Challenge: Enrolling elders and persons with physical disabilities took significantly longer than for individuals with intellectual/ developmental disabilities
Lesson Learned: Enrollment differs by population and needs to be taken into
consideration when developing
policies and procedures. 41

42. Challenges & Lessons Learned (cont’d)
Challenge: Elders and persons with physical disabilities were confused about the role of the Supports Broker compared with the role of their Care Coordinator.
Lesson Learned: Need to lay out the roles and responsibilities clearly and compared to other care management roles. 42

43. Challenges & Lessons Learned (cont’d)
Challenge: Elders and persons with physical disabilities in CD didn’t feel they had to comply with State’s Electronic Visit Verification(EVV)System – wanted more flexibility in reporting workers’ time on job.
Lesson Learned: State needed to build more flexibility into the EVVS for reporting workers’ time on job. 43

44. Promising Practices Prescriptive requirements
Contractor Risk Agreement (CRA)
MFP incentive
consumer direction enrollment benchmark
Care Coordinator
Introduces consumer direction at enrollment and annually 44

45. Promising Practices (cont’d)
VF/EA FMS contract
VF/EA FMS organization tasks
Enrollment and payroll management
Required to contract with the managed care entities (MCEs)
Supports Broker tasks
Train members
Assist with completion of all onboarding tasks (enrollment) 45

46. Promising Practices (cont’d)
Monitoring provision of services
Electronic visit verification
Care coordinator required contacts
Monitoring quality of care
Customer satisfaction surveys
TennCare and VF/EA FMS 46

47. Key Outcomes Increased quality of life and care for members
95% prefer choosing own workers
97% like being in charge of directing their services
91% think their life and health are better since using consumer-directed services
99% of services provided when needed 47

48. Recommendations
Claims process between managed care organizations and VF/EA FMS entity
Implement tracking mechanism immediately
VF/EA FMS Request for Proposal Process 48

49. Recommendations (cont’d)
VF/EA FMS Readiness Review
Member/Representative Satisfaction Surveys
Use results 49

50. Processing and Discussion
What is your biggest insight about what you just heard?
What do you could do in your State/program that is similar?
What do think the challenges might be to implementing self-directed services under a MLTSS delivery system in your State/program? 50

51. Selected Resources
ASPE -Truven Five State Study:
Financial Management Services and Managed Long-Term Services:
Mathematica/CMS Report: Selected Provisions from Integrated Care RFPs and Contracts: Participant Direction:   51

52. HCBS TA Available
Determining what authority will best meet your objectives.
Providing guidance on major features of §1915(i), including developing needs-based criteria.
Providing guidance on integrating §1915(i) with other services, such as §1915(c) waiver services.
Providing guidance on major features under a §1915(c) or §1115 waiver or §1915(i), (j) or (k) SPA, including implementing self-directed services and developing person-centered plans & budgets. 52

53. HCBS TA Available (cont’d)
Providing guidance on implementing self-directed services under MLTSS.
Providing clarification and assistance with the CMS waiver and state plan amendment application processes.
Identifying and addressing common barriers to implementation. 53

54. Examples of Topics for HCBS-TA
HCBS under §1915(i), (j) and (k) SPAs and §1915(c) and § 1115(a) waivers
Self-directed Services under §1915(i) (j) and (k) SPAs and §1915(c) and §1115(a) waivers
§1915(k) Community First Choice Option SPA
Person-centered Philosophy and Systems
Person-centered Planning
Individual Budgeting
Need Assessment
Positive Behavioral Supports 54

55. Examples of Topics for HCBS-TA (cont’d)
Supported Employment
Community Integration
Rate Setting Methodologies
Managed Care including Managed LTSS
Other Areas as Needed by States 55

56. Where to Find Help To request TA: http://www.hcbs-ta.org/request.aspx
For additional information: 56