Community First Choice Implementation Council Meeting

1. Community First ChoiceImplementation Council Meeting January 27, 2012

2. 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.

3. 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.

4. Community First Choice (CFC) The Department plans to include all required and optional services allowed under proposed federal regulations. Specifically, these services are: 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).

5. 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.

6. 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 self-direction. • 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.

7. 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.

8. Proposed Process for Enrolling in Community First Choice At the initial assessment or next annual re-assessment, 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.

9. 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.

10. Self-Direction vs Agency Services • Self-Direction • CMS recommended Maryland review states currently implementing 1915(j) State Plan services regarding self-direction. • 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

11. Questions to be Answered • How much personal responsibility will a self-directed 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?

12. Community First Choice Timeline January 2012 July 2012 January 2013 July 2013 Host Monthly Implementation Council Meetings Collect data on projected hours for each waiver Review rates for personal care providers Begin phase-in enrollment of CFC participants based on new and annual assessments Determine model for self-direction Begin re-enrolling all personal care providers and develop registry Develop a CFC procedure manual Review Quality Assurance measures Begin procurement of fiscal intermediary Begin consumer and provider training Refine provider qualification requirements Draft and submit State regulations and State Plan Amendment

13. 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 self-direction program CFC@dhmh.state.md.us

14. Maryland Disabilities Forum (MDF) and The Freedom Center (TFC) Re: Community First Choice Implementation Council Meeting, January 27, 2012 MDF/TFCResponses to DHMH Power Point Presentation

15. Questions to be answered (DHMH Power Point Presentation Slides 11 to 13 ) Slide 11 • How much personal responsibility will a self-directed person in CFC have? • How will that person get the services they need? • How should service funding be allocated to each participant? Response TBD • What about those receiving care from a live-in provider? Response TBD • What provider qualifications are necessary? Response TBD • 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.

16. Slide 11, Question 1: How much personal responsibility will a self-directed 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

17. 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.

18. 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 choiceof receiving vouchers, direct cash payments, using a financial management entity* or entering into a co-employment 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 paying claims.

19. 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 • 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.

20. 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.

21. 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/

22. 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 re-examined 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.

23. 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 Budgetingis another basic element of self-direction model. In other states, counselors rather than case managers may assist in developing individual budgets, spending plans, etc.

24. 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.

25. 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 : • creating a new and separate system or service that provides trained counselors, or • modifying an existing case management system to include the counseling service. • If a state chooses the latter option, case managers will have to undergo counselor-specific training and have a manageable caseload.

26. 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.

27. Slide 13: What more information does the council want to review at its next meeting? • Other State Plan self-direction programs (2 reports, 8 programs) • 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/ • Other Resources: • PAS Center for Personal Assistance Services • National Resource Center for Participant Directed Services (NRCPDS