Owning the process in Virginia

1. Owning the process in Virginia Individual Budgeting Saturday August 10 10:45 AM — 12 PM

2. TODAY’ s description • “Owning the Process: Individual Budgeting” connects the compelling stories of five citizens who oversee the payment from tax dollars for the public services they receive. • A service system that works this way uses the process of person-centered planning to develop an individualized plan of services and an individualized financial plan to control the funding mostly from Medicaid.

3. Today… • Not about personal budget or money management • First & Foremost Advocate and Sister • Self-determination/ Disability Justice • What works best for individuals • Not about what works best for systems of support

4. Self-Determination

5. Self-Determination • Civil Rights • About Transfer Of Control • Meaningful Life In & Among Community • Tools of implementation

6. By any other name… • Personal Budgeting • Self-directed services/supports • Participant controlled • Consumer direction • Budget Authority • Individual Budgeting • Money Follows the person • Individual Resource Allocation

7. SD Founding PRINCIPLES Freedom Authority Support Responsibility Conformation

8. Arrangements that Support Self-Determination • Authority over resources is not an end by itself • But control over money is the central element of a power shift

9. “Individual Budget” holistic At first, about the person’s whole life Planning takes into account the person’s whole resource picture • Entitlements • Earnings • In-kind contributions from allies • All public funds • System wouldn’t allow for this. The puzzle is just too magnificent

10. Arrangements that Support Self-Determination Having an Individual Budget is necessary but not sufficient. Arrangements that support Not be limited by “fitting dreams” into Waivers “authorized categories”

11. A little background on Individual Budgeting • Traditionally money is allocated to agencies, service providers work for the agency, and the individual with a disability is a recipient of the agency’s services. • In person-directed, this changes. Money is now allocated to individuals. • In a participant direction model, money is not sent directly to an individual, but rather to a fiscal agent or intermediary who is answerable to the individual with disabilities

12. Things change and evolve.. • States have different methods for deciding how much money is allocated to an individual. • Now mostly about services • May “Own The Process” • In the end, the agreement by the individual and allies is to implement the plan within the overall budget amount.

13. CMS says • An individualized budget is the amount of funds that is under the control and direction of the individual. • Participants may have decision-making authority over how the Medicaid funds in a budget are spent. CMS refers to this as "budget authority.“ • States must describe • the method for calculating the dollar values of individual budgets • based on reliable costs and service utilization, • define a process for making adjustments to the budget when changes in participants' person-centered service plans occur and • define a procedure to evaluate participants' expenditures. • Is this under control and direction of the individual?

14. How is an individual budget developed? Come a long way …

15. “Top-down or from the Bottom-up”. (Mosley, 2005). • In the top-down method, key decision makers use a standardized assessment to set a general budget level prior to developing a person-centered plan. • In the bottom-up approach, the budget is developed through discussion and negotiation during person-centered planning

17. Participant Enters System Assessment/ PCP Bottom Up Top Down PCP Completed Total dollar amount of benefit determined Total dollar amount of benefit determined PCP completed Amount of Budget that is self-directed Services & support goals in PCP

18. Bottom UP Process • First, the plan is developed using a person-centered planning process • Second the budget amount is determined from the plan, calculating costs per unit of service at specific rates and aggregating these costs • Finally, the specific arrangements the participant will, or may, utilize to control and direct providers are determined • Then, the budget may be authorized in companionship with the plan

19. Bottom Up budgeting Step 1: Individual enters System Step 2: Person Centered Planning Step 3: Person Centered Plan facilitated Step 6: Individual receives services & support outlined in Plan of Service & Person Centered Plan Step 4: Plan of Service & Total dollar amount of benefit determined Step 5: Amount of Budget that is self-directed 19

20. Owning the process

21. From the Top Down

22. Top Down method • Involves using assessment of support needs and other data to determine the amount of the budget, following which a plan of services & supports is developed that may not exceed the prospectively determined amount • The prospective method involves a budget cap; • the fastest growing method is the SIS, or Supports Intensity Scale • Virginia is following suit • All the methods are crude estimates

23. Funding by “Kind of Person” • Most states have set up this type a funding formula • Usually 4 to 10 “kinds of people” • From High Need to Low Need • Based on medical, behavioral, and self-help levels of need • But not the person’s existing connections, or hopes & dreams & relationships • Once the “Type of Person” or “Group” or “Band” is set, the person’s funding future is determined • And sometimes …. it’s pretty much forever. - Conroy 2012

24. Level-Based Budget Allocations • States carefully chose a tool to measure support needs. • In this regard, the SIS appears to be at least as useful as other assessment tools and shows a consistency of results across states boundaries that is useful for forming individual budgets or individual budget levels that meet CMS guidelines. -HSRI/ AAIDD April 2009

25. Person-Centered Planning, But NOT Person-Centered Budgeting? • The fastest growing method is the SIS, or Supports Intensity Scale • All the methods are crude estimates • They are the farthest thing possible from Person-Centered • Why after 30 years …. • Do we accept Person-Centered Planning ….. • But NOT Person-Centered Budgeting? -Conroy 2012

26. However it is derived: • If the individual does not have direct control over a fixed amount of resources so as to be able to select and direct providers and support • If the individual does not know what the budgeted amount is, and what it is intended for • It is not self-determination or self-directed

27. VA plan • PHASE II (September 2013 – June 2014) • 2.1 Conduct a cost/rate study of the current Medicaid ID/DD/Ds Waivers. • 2.2 Submit recommendations to Virginia to transition to an individual budgeting or state-level methodology approach which incorporates the Supports Intensity Scale (SIS) to determine waiver funding necessary to provide needed and appropriate supports to individuals with ID.. • 2.3 Propose a new rate structure for approval and/or adoption. • 2.4 Evaluate the current SIS processes and data from the thousands of SISs that have already been administered. • 2.5 Provide recommendation for levels and/or ranges to use for individual resource allocation if Virginia decides to transition to individual budgeting. • 2.6 Conduct an Impact Study of the recommended system changes describing funding needs and other areas that will be affected. (i.e. IT, claims processing edits, rate changes, test affected policies and regulations, and needed operational changes) • 2.7 Align all changes with DBHDS’ Quality Management System

28. Owning the Process: Individual Budgeting Viewers Guide

29. Owning the Process: Individual Budgeting Vview DVD Viewers Guide

30. History of Self-Determination The history of any self-determination movement is about people looking for more individual freedom and independence.

31. Principles of Self-Determination

32. Tools of Self-Determination • Individual Budget • Person Centered Planning • Fiscal Intermediary • Independent Supports Coordination or Supports Broker • Circle of Support

33. What MPF Local Leaders Say

37. Quotes from Leaders in Self-Determination Who Reviewed Owning the Process

38. Credits

39. Resources www.mifreedom.org