Transcript Community First Choice Implementation Council Meeting

Community First Choice
Implementation Council Meeting
January 27, 2012
Community First Choice (CFC)
• The federal government created an optional State Plan program under
the Affordable Care Act for states to implement called Community First
Choice that includes a 6% enhanced FMAP.
– As a State Plan service, participants do not need to meet budget
neutrality, however waiver enrollees receiving CFC as a service do
need to meet their own waiver requirements
– Slots are not limited in CFC and the program does not have to be
renewed.
• Optional State Plan benefit to offer Attendant Care and related supports
to individuals, providing opportunities for self-direction.
• CMS is still discussing policy decisions.
– Specifically, CMS is discussing whether all CFC participants must
meet the State’s institutional level of care, or whether CFC also is
available for people who require attendant care but are not at
institutional level of care.
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Who is eligible?
• Anyone currently receiving State Plan
services or participating in a waiver
program.
– Community First Choice (CFC) does not
create a new eligibility category.
– Waiver participants are eligible to receive CFC
State Plan services.
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Community First Choice (CFC)
The Department plans to include all required and
optional services allowed under proposed federal
regulations. Specifically, these services are:
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Personal / Attendant Care;
Personal Emergency Response Systems (PERS);
Voluntary training for participants;
Transition Services; and
Services that increase independence or substitute for
human assistance.
• Goods and services must relate to identified goals and
needs within the person’s plan of care.
• For example, small kitchen appliances (such as
microwave ovens) and home modifications (such as
accessibility ramps).
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Getting These Services under CFC
• Services offered under CFC would no longer be
covered as a waiver service, but rather covered
as a State Plan service. Waiver participants are
eligible to receive all State Plan services.
• Only the services listed in the proposed
regulation are allowable under CFC.
• Certain administrative functions are also eligible
for the increased match, such as nurse
monitoring, case management, and fiscal
intermediary services.
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Community First Choice (CFC)
• CFC is not creating a new eligibility standard.
– CFC is a consolidation of current State Plan eligible
participants who receive personal care into one
robust program offering additional services and selfdirection.
• The program is expected to grow based on
increased utilization due to:
– Increased services to certain current participants,
– Participation of currently eligible participants not
receiving services, and
– Improved reimbursement to most providers.
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Improvements possible under CFC
• In addition to services offered under CFC, with
the enhanced match the State would be able to
also provide the following:
– Enhanced quality assurance.
– A provider registry.
– Trainings to providers.
– Coordinated rates across programs.
– An option to develop a back-up system.
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Proposed Process for Enrolling in
Community First Choice
• At the initial assessment or next annual reassessment, each participant would choose a
model as part of his/her plan of care: agency or
self-directed.
• All participants develop a person-centered plan
of care.
• Participants who choose self-direction would
have assistance available to manage their own
budget with help from a fiscal intermediary and
nurse monitor.
• All participants would be allowed to keep their current
independent provider if they choose to self-direct.
– Waiver participants would not lose current services.
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Self-Direction vs Agency Services
• Agency
– A person entering CFC may select to receive
services through an agency.
– The participant maintains his or her right to
select a provider and may access agencies
through one online registry.
– The State will pay each agency for hours
billed.
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Self-Direction vs Agency Services
• Self-Direction
– CMS recommended Maryland review states currently
implementing 1915(j) State Plan services regarding selfdirection.
– A person will develop a service budget within his or her
plan of care. The service budget may be based on:
• vouchers;
• direct cash payments; or
• use of a financial management entity to assist in obtaining
services.
– Under self-direction, there are no federal restrictions on
family providers prescribed in current guidance.
– States may restrict providers of self-directed services.
– Maryland regulations in State Plan MAPC currently
exclude spouses, parents of dependent children, and other
legally responsible adults from allowable providers
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Questions to be Answered
• How much personal responsibility will a selfdirected person in CFC have?
• How will that person get the services they need?
• How should service funding be allocated to each
participant?
• What about those receiving care from a live-in
provider?
• What provider qualifications are necessary?
• What quality assurance measures should be
taken when designing the program?
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Community First Choice Timeline
January 2012
July 2012
January 2013
July 2013
Host Monthly Implementation Council Meetings
Determine model for
self-direction
Review Quality
Assurance measures
Refine provider
qualification
requirements
Collect data on projected
hours for each waiver
Review rates for
personal care
providers
Begin re-enrolling all
personal care providers
and develop registry
Develop a CFC
procedure manual
Begin procurement of
fiscal intermediary
Begin consumer and
provider training
Begin phase-in
enrollment of
CFC
participants
based on new
and annual
assessments
Draft and submit State regulations and State
Plan Amendment
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Next Steps
• What more information does the council
want to review at its next meeting?
– Other State Plan self-direction programs
– A list of decision points for designing a selfdirection program
[email protected]
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Maryland Disabilities Forum (MDF) and The Freedom
Center (TFC)
Re: Community First Choice Implementation
Council Meeting, January 27, 2012
MDF/TFC Responses to DHMH Power Point
Presentation
Questions to be answered (DHMH Power
Point Presentation Slides 11 to 13 )
Slide 11
1.How much personal responsibility will a self-directed person in CFC have?
2.How will that person get the services they need?
3.How should service funding be allocated to each participant? Response TBD
4.What about those receiving care from a live-in provider? Response TBD
5.What provider qualifications are necessary? Response TBD
6.What quality assurance measures should be taken when designing the program?
Response TBD
Slide 12 : Determine model for self-direction
Slide 13
1. Other State Plan self-direction programs
2. A list of decision points for designing a self-direction program.
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Slide 11, Question 1: How much personal responsibility will a selfdirected person in CFC have?
MDF/TFC Response:
The answer is all persons in CFC should have choices including maximum possible
individual responsibility and risk.
• This should definitely apply to the self-directed component of CFC Program.
• And opportunities for personal responsibility should also be included under the
agency based component of CFC .
• According to the National Resource Center for Participant Directed Services
(NRCPDS), “Choice is the hallmark of self-direction and this includes the choice
not to direct and to direct to the extent desired. Program designs should permit
individuals to elect the traditional service model if self-direction does not work for
them or to direct some of their services but receive others from agency
providers. *
*Developing and Implementing Self-Direction Programs and Policies: A Handbook,
National Resource Center for Participant Directed Services (NRCPDS), May 3, 2010,
page 1-2. http://www.bc.edu/content/dam/files/schools/gssw_sites/nrcpds/cc-full.pdf
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Slide 11, Question 1 (cont.): How much personal responsibility will a
self-directed person in CFC have?
A. Maryland’s CFC Self-directed component should include opportunity for two
consumer authorities:
• Employee Authority - individual hires, trains, manages, dismisses PAS worker
• Budget Authority - person manages an individual budget and has choice to
purchase goods and services
For example, a typical very self-directed model might be one that negotiates an
(adequate) budget for the year with the consumer and then the consumer manages
the dollars, sets the rate, frequency, etc.
B. The agency-based component included as a choice in Maryland’s CFC should
include features honoring the principle of choice by authorizing the service
recipients, if they prefer, to identify, and refer for hiring, the individuals they want to
work as their caregivers, and/or by involving the service recipient more directly in
interviewing and selecting their caregivers from a pool of potential workers provided
by the agency. In addition to choosing employees / caregivers, service recipients
should also have authorities such as (but not necessarily limited to) scheduling
workers, training employees, and managing back-up supports.
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Slide 11, Question 2: How will that (self-directed) person get the services they
need?
MDF/TFC Response:
• All CFC participants should have a range of choice of receiving vouchers, direct
cash payments, using a financial management entity* or entering into a coemployment arrangement with an “agency of choice” or “public authority”, or
receiving traditional agency-based PAS or PAS from a traditional agency
supporting choice or with a self-directed feel and philosophy. They should also
have access to consultant / support broker services.
• These choices are represented in Spectrum of PAS Models on next page.
• Consumer direction implies that consumers should be able to choose from a range
of flexible models of how they receive services or be able to put together a model
for themselves from a set of modular elements.
• Questions and comments likely to be heard from consumers and advocates:
– Why can't people with disabilities design their own personal arrangements?
– Why do they have to choose a "model"? Why isn't PAS alike for people with
DD and those with physical disabilities? These may seem like rhetorical
questions given the bureaucratic process we are in but what we are looking
for is as much room as possible for individualized designs.
* Note: In a 9/23/2011 presentation, DHMH indicated that all participants who choose self-direction would utilize a fiscal intermediary for
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paying claims.
Slide 11, Question 2 (cont.): How will that (self-directed) person get the services
they need?
MDF/TFC Response:
The Spectrum of Personal Assistance Services Models
From three different sources, we identified nine (9) different PAS Models:
Self-Directed Models: Fiscal Management Service (FMS) Models
(1) Fiscal Conduit : State or County (government agency) or Vendor : Disburses public
funds via cash or voucher payments to participants
(2/3) Government or Vendor Fiscal / Employer Agent: F/EA acts as an “employer
agent” for participants—performing payroll function (wages, withholding) on the
participant employer’s behalf .
(4) Agency with Choice: The agency and participants are co-employers of the workers
whom participants recruit and refer to the agency for hire and assignment back to
them.
(5) Public Authority/Workforce Council: Multiple-employer arrangement with
participants and independent or quasi –governmental entity, state or local
community-based service program, or human service department.
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Slide 11, Question 2 (cont.): How will that (self-directed) person get the services
they need?
MDF/TFC Response:
The Spectrum of Personal Assistance Services Models
Self-Directed Model: Other
(6) Consultant or Support Brokerage Services offer individuals assistance with
navigating program processes, paperwork, budget planning, and counseling. See
discussion of Self-Direction Counseling role on slides 22 to 25.
Agency – Based Models:
(7) Traditional Agency Model Supporting Choice: Under this hybrid model, provider
agency honors the principle of choice but the PAS worker is an agency employee.
(8) Traditional Agency with a Self-Directed Feel and Philosophy: Under this hybrid
model, traditional agency allows the service recipient to have as many Agency with
Choice freedoms as possible .
(9) Traditional Agency-Based Personal Assistance Services: puts the responsibility for
recruiting, hiring, managing and dismissing caregivers on an agency.
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Slide 11: How will that (self-directed) person get the services they need?
MDF/TFC Response (cont.) :
The CFC Council needs to address the following four (4) core elements* of
consumer-directed PAS programs:
•
•
•
•
Eligibility Assessment, including functional assessment, financial assessment, enrollment,
resource/service allocation, service planning, referral (if applicable), monitoring, and service plan
quality assurance;
Participant Support, including identifying workers / maintaining a registry, consumer training, and
consumer consultation on self-direction/Independent Living.
PAS Management Services related to personal assistants, including interviewing, hiring, firing,
enrollment, worker training, PAS supervising, and PAS quality monitoring; and
Financial Management Function, including maintaining legal status as employee of record,
timesheets handling, and payroll functions of withholding, issuing checks.
In addressing all these core elements, the Council should review information on the
functions are carried out in other states’ Self-directed PAS programs under the various
models. There is information in the sources cited in the footnote below and
elsewhere in the WORD version of this document sent to DHMH for CFC Council.
* Sources of Core Elements: (1) Consumer Direction of Personal Assistance Services in Medicaid: A Review of Four
State Programs, Kaiser Commission on Medicaid and the Uninsured, March 2008
http://www.kff.org/medicaid/upload/7757.pdf;
(2) PAS Fundamentals, World Institute on Disabilities (WID), http://wid.org/publications/pas-fundamentals/
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Slide 11: How will that (self-directed) person get the services they need? (Cont.)
MDF/TFC Response (continued):
• As far as the Eligibility Assessment Function, under self-directed PAS there should
be a non-medical/independent living assessment and service authorization
process (aka case management but really should be self-direction counseling); the
current MD-MAPC nurse case monitor role, function and orientation should be reexamined if not eliminated from the new CFC.
• Note: Slide 5 indicates that certain administrative functions are also eligible for the
CFC increased match, such as nurse monitoring, case management, and fiscal
intermediary services.
• Note: Slide 8 indicates that CFC participants who choose self-direction would have
assistance available to manage their own budget with help from a fiscal
intermediary and nurse monitor.
• The Self Directed Model requires a Self-Directed Counseling (aka “flexible case
manager” role. See Addendum on next page regarding this role.
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Slide 11: How will that (self-directed) person get the services they need? (Cont.)
ADDENDUM to information sent to CFC Council
Self-Directed Program Counseling
• From previously sited NRCPDS Handbook: Counseling is a key supportive service
in self-direction programs.
• Counseling is providing information about self-direction and assistance and training
with self-directed tasks as needed to individuals electing to direct their services.
• States use a variety of terms to describe the counselor’s role, including support
broker, service coordinator, flexible case manager, consultant, advisor, and
community guide [and consumer relations].
Individual Budgeting is another basic element of self-direction model. In other states,
counselors rather than case managers may assist in developing individual budgets,
spending plans, etc.
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Slide 11: How will that (self-directed) person get the services they need? (Cont.)
ADDENDUM to information sent to CFC Council (cont.)
• Regardless of the name used, the goal of counseling is the same: to offer
flexible and personalized support to ensure that self-direction works for the
participants who choose it.
• To be effective, counselors must be able to work with a wide range of
participant skill sets, practice person-centered planning, and assist
individuals to make informed choices that are consistent with their needs
and will help them achieve their goals.
• Chapter 6 of the Handbook discusses the key components of counseling
and how programs can ensure quality counseling services. It also discusses
the differences between counseling and traditional case management and
describes various counseling models states use, including those that have
combined the case manager and counselor roles.
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Slide 11: How will that (self-directed) person get the services they need? (Cont.)
ADDENDUM to information sent to CFC Council
•
•
Transferring [some] authority and control over services from professional case
managers to participants aided by a counselor. requires states to develop a new
system by either :
1. creating a new and separate system or service that provides trained counselors,
or
2. modifying an existing case management system to include the counseling
service.
If a state chooses the latter option, case managers will have to undergo counselorspecific training and have a manageable caseload.
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Slide 12: The first thing on timeline starting in Jan, 2012 is “Determine model for
self-direction”
MDF – TFC Recommendation
•
See response to question 2, DHMH slide 12 concerning ensuring
consumers ability to choose from a range of flexible models or be able to
put together a model for themselves from a set of modular elements.
•
The Council should carefully examine these models, preferably with
technical assistance / explanations from expert consultants, to determine
which (any or all) of these models should be available to CFC participants.
Note: Procurement of a fiscal intermediary is already in the DHMH time
plan.
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Slide 13: What more information does the council want to review at its next meeting?
1. Other State Plan self-direction programs (2 reports, 8 programs)
2. A list of decision points for designing a self-direction program.
Important Distinctions Between Medical and Independent Living PAS Models, in
PAS Fundamentals, World Institute on Disabilities (WID), page 27.
http://wid.org/publications/pas-fundamentals/
3. Other Resources:
•PAS Center for Personal Assistance Services
•National Resource Center for Participant Directed Services (NRCPDS
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