1. Long-Term Care Policy Summit Suzanne Crisp Director of Program Design & Implementation Boston College

2. Today’s Discussion Balancing Incentive Program Community First Choice Option 2

3. Balancing Incentive Program Purpose – Encourage States to rebalance budgets Shift Medicaid dollars from institutions to the community Enhanced FMAP to increase diversions and access to HCBS 5% if less than 25% LTSS spending in non- institutional settings 2% if less than 50% LTSS spending in non- institutional settings Enhancement ends after two years 3

4. Requirements Aging and Disability Resource Centers (ADRC) Single point entry or no wrong door - Uniform assessments process Eliminate conflict of interest 4

5. Conflict Free Case Management Desire of CMS for years Eliminate:  Incentives for over or under utilization  Retain as clients through failure to promote independence  Focus on agent or provider convenience rather than person-centered practices Independent agent should not be influenced by variations in local or State funding Service plan based on needs-based criteria 5

6. Conflict Free Case Management Independent assessments and service plan development may not be performed by a provider that will then provide services Payment to the provider of services for evaluation and assessment cannot be based on the cost of the resulting plan of care In rare instances, service providers may evaluate and assess but firewalls must be present 6

7. Section 1915(k) Community First Option Section 6078 of the Affordable Care Act 2010 Provides vehicle to use consumer control to provide personal assistance services Consumer control  Individual exercises as much control as desired to select, train, supervise, schedule, determine duties, and dismiss the attendant care provider

8. Community First Choice Option Attendant services & supports to assist in accomplishing activities of daily living (ADLs), instrument ADLs, and health-related tasks through hands-on assistance, supervision, or curing Back-up System must be in place Transitions costs required Allows for the provision of services that increase independence or substitute for human assistance to the extent that expenditures would have been made for human assistance 8

9. 1915(k) Recognizes Three Models  Agency-provider model Entity contracts to provide services directly through employees or arranges for the services under the direction of the individual Agency acts as the employer of record Individual must have significant and meaningful role in management of services  Self-directed model with service budget FMS must be available Reimbursed at service or administrative FMAP rate Cash or vouchers permitted Participant is employer of record  Other service delivery model States may propose other models

10. Support Services Required Operate with person-centeredness Provide support system  Assesses and counsels  Provides information  Includes information on risks and responsibilities including tools  Develops a backup plan  Assessors are free from conflict  Data collection

11. Section 1915(k) May offer goods and services Home modification excluded unless tied to increased independence or sub for human asst. Targeting not permitted Must offer statewide Current activity – CA, MN, AK, NY, AZ Differences between the (j) and (k)  Enhanced funding (k)  Level of Care (k)

12. Section 1915(k) Continued Allows a cash benefit Prospective payments allowed Target population must meet level of care FMS reimbursed at service or admin rate Requires creation of a Development and Implementation Council Enhanced FMAP at 6% Requires a face-to-face assessment (telemedicine) annually Person-centered planning required

13. The Possibilities Include all participant directed program under one authority that offers enhanced match Replace State Plan Personal Care and Waiver Attendant Care with Community First Choice and receive Enhanced Match (6%) Section 1915(i) Targets those not meeting LoC Use FMS Support Structure to Manage all PD 13

14. Challenges of Community First Choice Create sufficient supports to ensure program integrity Case Management, care coordination and self- directed counseling –YIKES! Establish and maintain a comprehensive continuous quality assurance system Collect and report information for Federal oversight and the completion of a Federal evaluation Serves a LoC population only 14

15. Challenges of Community First Choice Option Must receive one waiver service to maintain financial eligibility Consumer Control – how broad, how narrow Coordinating assessment and service planning with other authorities Who has final say in care coordination?  Waiver case manager  Targeted case management  Health Home coordinator 15

16. Majority of States have more than one Participant-Directed LTSS Program 16

17. States with less than 1,000 PD articipants States with 1,000 but less than 5, 000 PD articipants States with 5,000 but less than 10, 000 PD articipants States with more than 10, 000 PD articipants Majority of States have 1000 – 5000 Self-Direction LTSS Participants Hawaii 17

18. Participant Workers recruited and report to agency Program and agency set tasks Agency specifies salary and benefits Normal work hour schedule Worker training required by agency Case managers determine needs & services Participant Recruits and manages workers Sets tasks Specifies salary and benefits (optional) Assigns flexible work hour schedule Trains/ arranges worker training Makes decisions about needs and services Traditional ServicesParticipant-Directed Services

19. Positive Impact of Life Cash & Counseling participants were up to 90% more likely to be very satisfied with how they led their lives.

20. Assessed Needs Met Cash & Counseling significantly reduced participants’ unmet personal care needs.

21. Caregivers Better Satisfied Primary caregivers were significantly more satisfied with their lives in general.

22. Virtually No Fraud or Abuse Cash & Counseling did not result in the increased misuse of Medicaid funds or abuse of participants

23. Essential Elements of Participant Direction Person-Centered Practices Individual budget Information, Assistance and Supports Financial Management Services 23

24. Commonly Used Terms Participant-Directed Counselor: Individual who works with the participant in designing their plan. The person the participant goes to with questions. McInnis-Dittrich, Simone, and Mahoney (April, 2006) consultantskills trainer support broker counselorcase manager participant- directed counselor

25. Understand Federal Employment Obligations Internal Revenue Services – uniform across states Payroll for participant-directed services is different Separate Employer Identification Number required? Are guidelines clear for completing forms, filing, withholding, and depositing If reconciliation is necessary – can you perform this? A few forms: IRS Forms – 940, 941, 2678, W-3, W-4, 1099, 1096 When are numbers retired? How do you calculate Federal unemployment taxes? When do you deposit? How do you manage overpayments of SSA and Medicare Taxes

26. Common Findings – Self Direction Rebalances Service Dollars Acute care and high costs services are lower for those self-directing, however, basic service costs increase Per capita Medicaid costs are less for self-directed participants than traditionally served participants Costs per hour are lower for those using self- direction than for agency services If the cost of counseling and FMS are considered in the design of the program, these are at least neutral 26

27. Tangible Costs Considerations Hiring family members – reduce unemployment or public assistance Income tax implications Service costs – Participants receive services Case management – add on – PD in addition to CM tasks Financial Management Services Admin staff to run a PD program – cost vs efficiency

28. Intangible Considerations Satisfaction/Safety with PD QOL impacts health – health impacts $ Responsibility and authority can lead to good stewardship Caregiver satisfaction

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30. Contact Information www.suzanne.crisp@bc.edu 30