1. Self Direction Redesign November 5, 2014 Association of Day Services Providers

2. Today’s Agenda Final Self Direction Model Current Status of Self Direction Questions

3. Today: CSS Budget 3 1. Self Hired Staff 2. Purchased Services 3. Contractors/v endors 4. State Paid /Housing subsidies 5. 17.5% Admin CSS Price

4. CMS Mandated Changes 4  The monthly unit is unacceptable.  Each element in a person’s current CSS plan that is eligible for Medicaid funding must be separately billed to eMedNY.  FMS reimbursement must be separately billed; based on the level of support an individual elects to purchase.  Effective date of conversion for all CSS plans is 10/1/14.

5. CMS Mandated Changes  Each self-directed service component in a person’s CSS plan must be aligned with an HCBS Waiver service.  The rate paid for self-directed services cannot exceed the amount paid for provider-controlled services  Medicaid payment is limited to the PRA, no exception to allow up to prior cost of services 5

6. What Remains the Same

7. 7 Will continue to allow the person self directing to: make decisions about who works for them. recruit people to work for them. decide what they need staff to do to help them, how many hours of help they need and when they need that help. supervise their staff and change staff if they aren’t satisfied. Employer Authority

8. Will continue to allow people who self direct to: make choices about the services they need. make decisions about their services and supports based on their funding. decide what services are paid for and who is paid to provide them; the person decides how much to pay self-hired staff manage their OPWDD budget in a responsible manner. 8 Budget Authority

9. Required reforms will create opportunity for design changes that will make self directed supports choice clearer and more direct There will be increased opportunity to expand self direction options and streamline access to self directed options Educational opportunities will be provided on all of the changes. 9 Self Direction Expansion

10. Self-Directed Services Align w/ HCBS Services 10 Self-Hired /Individual Directed Services** Services Supporting Self Direction Community HabilitationLive-in Caregiver (monthly unit) SEMPSupport Brokerage (1/4 hour unit) RespiteFiscal Intermediary (monthly unit) Individuals Directed Goods & Services ($10 per unit) Community Transition Services (one-time payment) **Billed in ¼ hour units

11. Self – Hired (FI Supports Person) Self-Hired - Individual directs Staff Salary Staff Schedule Arrangements for Back-up Staff Person has option to be Employer of Record FI Supports Individual with payroll/admin functions and other staffing supports as chosen (such as CPR training) 11

12. Individual Directed Goods and Services (IDGS) Service Description: Are services, equipment, or supplies that addresses a need in the individual’s service plan. For individuals living in non-certified settings. Can be used for Transportation, Small Kitchen Appliances, Laundry services, Chore services Annual cap is $32,000 12

13. Camp Funding may be requested for the cost of summer camp in a self-directed plan for a camp that is able to provide the needed safeguarding supports and supports to achieve the person’s valued outcomes. Camps can be either focused on supporting individuals with disabilities or camps that are available to the general public. Directly related to a valued outcome.Annual Cap of $4,000

14. Community Classes & Publicly Available Training/Coaching Classes available to the general public in any subject area that relates to a person’s valued outcomes (Art, Dance, Exercise, Cooking, Computer Training, Etc.) Sessions with a private trainer (physical education/exercise) may be covered as long as the service relates to a valued outcome). Classes must be related to a habilitative need in the individual’s person-centered plan and not just for recreational purposes. Classes must be non-credit bearing; IDGS funding is for non-matriculating students. Not to exceed the published fees as outlined in the entity’s published course fees.

15. Coaching/education for parent(s), spouse and advocates. IDGS funding is for Parent/Spouse/Advocate to attend/participate in educational opportunities (not covered by other public programs) that assist participants and those close to them to achieve goals established in the individual’s service plan. Self-directing individual is over age 18 (Under 18 is through FET).May Include registration, and conference fees Annual cap $500/year based on Family Education & Training (FET) pricing parameters in 1915(c) HCBS waiver.

16. Clinician Consultants, Independent Contractors – Consultants/contractors are clinical specialists who are hired for the following purpose: Evaluate an individual’s habilitation plan; training self-hired staff in delivering the self directed plan.; evaluation of the effectiveness of the self-hired staff in carrying out the services in the self-directed plan Consultants/contractors services cannot replicate any service available through a third-party insurer, the Medicaid State Plan or the HCBS Waiver Service. Consultants must provide a written outline of services to be delivered prior to approval; consultants must provide an annual update of progress/provision of service and need to continue. The hourly amount paid to the therapist cannot exceed the 90th percentile for the regional hourly wage for the therapeutic or consultant’s professional discipline

17. Clinician (Direct-Provision of Therapies/ Therapeutic Activities Not Otherwise Funded in the State Plan) Hippo Therapy:Therapeutic Riding & Equine-assisted ActivitiesAquatic, Art, Massage, Music, Play TherapyAll Services – Ordering, Treatment Plan & Documentation RequirementsSee detailed description in IDGS chart

18. Health Club/Organizational Memberships/ Community Participation Health club memberships; Community membership dues -- Funding for a gym, health club or other community organization membership may be included in the self-directed plan for reasons of health and fitness or community integration in accordance with the participant’s valued outcomes. Membership is for individual only; no family memberships allowed with IDGS funding. The club/organization must offer open enrollment to the public, and cannot be a private club with a closed membership where membership is available by invitation only. An individual may have multiple memberships to health clubs. Annual cap $1500/year.

19. Household-Related Items and Services Item cannot be funded through any other funded program and may include Appliances that assist a person to live more independently (i.e., a microwave oven for someone who cannot safely use a stove or oven) Appliance must benefit the individual and be related to a valued outcome as well as be related to health and safety. Household support (cleaning, minor maintenance, snow removal, lawn mowing) only for individuals not living in the family home. Note: The Community Transition Services (CTS) waiver service and funding cap remains separate from IDGS funding in this category. Annual cap $1500/year.

20. Paid Neighbor Stipend paid to neighbor to be “on-call” to assist a person who lives independently. If the paid neighbor is called upon to provide direct services, he/she is paid an hourly wage for the delivery of self-hired community habilitation. The specific duties are defined in a contract signed by the paid neighbor and the Fiscal Intermediary. Monthly cap $800

21. Self-Directed Staffing Support Assistance with scheduling self-hired staff and with assisting the person to complete staffing related paperwork Not to duplicate FI employer responsibilities or Broker services related to development of the person’s self directed plan. The ‘self-hired’ staff person providing this support is not a staff person of a NFP agency and is not a person who is active in assisting the person with decision- making regarding his/her self directed services Not to exceed payment of $20/hour

22. Transition Programs for Individuals with IDD Tuition for non-credit bearing transition programs for individuals with IDD who have already completed their educational program (i.e. ‘aged out’). The coursework must address a person’s valued outcomes and address skill building and employment outcomes. Programs may be provided in non-site based settings, on college campuses, but not in locations certified by OPWDD. Coursework may include training on personal care skills, and socialization skills; training is provided to support vocational outcomes for the person. To be funded via a person’s self direction budget, the program cannot be funded by ACCESS-VR, IDEA or other funding sources. Services are time-limited and cannot exceed a two year timeframe.No room and board costs are fundable. Published fees cannot be exceeded. Per class limit for tuition is $350/course. Where tuition is on a monthly basis, not to exceed $800/month

23. Transportation Funding may be requested for the cost of service related transportation that is directly related to valued outcomes, safeguards and services identified and approved in the self-directed plan. Reimbursement for service related miles may be made to:Staff person who drove his/her personal vehicle to a service related activity, Participant who drove or was driven in his/her personal vehicle to a service related activity, or Friend or family member who drove his/her personal vehicle to a service related activityNo cap but must be consistent with published rates

24. Proposed FI Choices Level 1 FI minimal involvement – FI might just bill IDGS, or pay housing subsidy Level 2 Individual manages staff hiring, negotiates wages Individual is Employer of Record FI supports individual with payroll/admin functions, performs background checks, same duties as Level 1 Level 3 Current model – FI manages all self-directed services for individual Assists individual in managing staff; provides training to individual on his or her employer responsibilities. Same duties as Level 2 24

25. Agency Supported Self Direction Individual selects staff and agency hires staff (co-management) Person has employer authority Agency is Employer of Record Wage within agency scales for staffing Individual Purchases HCBS services from a voluntary Medicaid provider Clinical Oversight Backup Staffing Program Management Behavioral Training Individual chooses to purchase services at provider wage which includes: 25

26. Direct Medicaid Purchased Services 26 Individual can choose to purchase HCBS Waiver services through a traditional voluntary Medicaid provider: Community Habilitation RespiteSEMP Day Habilitation Pathway to Employment Prevocational Services

27. Implementation Status Weekly CO workgroup meetings and calls with the SD Liaisons Technical Assistance being provided; new Guidance has been issued Meetings with FIs individually and group to review changes and strategize solutions Training to MSCs and Brokers underway More than half of the total plans have converted

28. We Want You to Know OPWDD is committed to ensuring: Continuity of supports - we expect almost all supports will continue uninterrupted Provision of needed technical assistance for plan conversions Opportunities for education and discussion will be available on a statewide and regional basis 28

29. Challenges Encountered PRA changes impact service budgets FI rate change to monthly fee – Need to ensure that costs are sufficient to cover FI tasks Direct clinical supports not allowed as duplicative of state plan services Employment support concerns – job developers No payment for experimental therapies Behavioral consultation – regional concern

30. Transition Solutions Identified Continuity of Care Provisions Education regarding Options to Manage Conversions Business Model Reviews by FIs Transformation Grants with Opportunities of Innovation in Self Direction

31. Summary Changes are required – opportunity to make changes to support growth of self direction Transformation focus continues to be on expansion of self direction

32. Opportunities for Self Direction MSCs can connect interested individuals to self direction Request for self direction through Front Door if new to services and through Service Amendment if want a change Self Directed plans can blend agency supported and self hired staff supports for customized Person Centered plan

33. Questions??