Providing and Coordinating Financial Management & Supports Brokerage

1. Providing and Coordinating Financial Management & Supports Brokerage US DHHS/OASPE Sponsored Government and Vendor Fiscal/Employer Agent Workshop November 2, 2007, Baltimore, MD

2. Welcome & Introductions • Sandy Barrett, Cash & Counseling National Program Office • David Horvath, Public Partnerships, LLC • Marise McFadden, New Mexico Aging and Long Term Services Division – Mi Via Program • Bill Ditto, New Jersey Division of Disability Services – Personal Preference Program

3. Session Overview Basic Design Considerations Supports for Participant Direction Models of Financial Management and Supports Brokerage • Combined F/EA and SB: West Virginia Personal Options • Separate F/EA and SB: New Mexico Mi Via • Moving from Multiple to Single Vendor: New Jersey Personal Preference Audience Discussion

4. Participant-Directed Service ModelsBasic Design Considerations • What opportunities will be available for participant direction? • How will the state provide and pay for supports for participant direction? - Financial Management Services- Information and Assistance in Support of Participant Direction • How will the state (and providers or vendors) ensure communication, cooperation, coordination, and collaboration?

5. Opportunities for Participant Direction (Employer Authority, Budget Authority, Both) Budget Authority • Participant has authority and responsibility to manage budget • Varying levels of budget authority Employer Authority(Hallmark of The RWJF Cash & Counseling model) • Participant is supported to recruit, hire, supervise and direct workers • Participant functions as common law employer or co-employer • Required for Independence Plus designation Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers, Centers for Medicare & Medicaid Services

6. Supports for Participant Direction Required by CMS Financial Management Services and Information and Assistance in Support of Participant Direction • Purposes and Functions • Types of Entities • Payment Authorities • Core Service Definitions • Guidance to States

7. Financial Management ServicesPurposes (a) To address Federal, state and local employment tax, labor, and worker’s compensation insurance rules and other requirements that apply when participant functions as the employer of workers and (b) To make financial transactions on behalf of the participant when the participant has budget authority Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers, Centers for Medicare & Medicaid Services

8. Financial Management ServicesTypes • Fiscal/Employer Agent (Government or Vendor)where the entity is the agent to the common law employer who is either the participant or his or her representative or • Agency with Choicewhere the participant and the agency function as co-employers of the participant’s worker(s). Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers, Centers for Medicare & Medicaid Services

9. Financial Management ServicesBasic Functions Assistance with Budget Authority • Act as a neutral bank, receiving and disbursing public funds, tracking and reporting on the participant’s budget (funds received, disbursed, and any balances (F/EA FMS) • Process and pay invoices for goods and services in the participant’s approved service plan (F/EA FMS) and, • Prepare and distribute reports (e.g., budget status and expenditure reports) to participants and other entities specified in the waiver (FEA and Agency with Choice FMS) Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers, Centers for Medicare & Medicaid Services

10. Financial Management ServicesBasic Functions Assistance with Employer Authority • Assist the participant in verifying worker’s citizenship or legal alien status (e.g., completing and maintaining a copy of the BCIS Form I-9 for each support service worker the participant employs) (F/EA and Agency with Choice FMS) • Collect and process support worker’s timesheets (F/EA and Agency with Choice FMS) and, • Operate a payroll service, (including withholding taxes from worker’s pay, filing and paying Federal (e.g., income tax withholding, FICA and FUTA), state (e.g., income tax withholding and SUTA, and when applicable, local employment taxes and insurance premiums); and distribute payroll checks on the participant’s behalf (F/EA and Agency with Choice FMS). Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers, Centers for Medicare & Medicaid Services

11. Financial Management ServicesAdditional Functions When specified in the waiver, an FMS entity may perform additional functions, including: • Executing provider agreements on behalf of the Medicaid agency or • Brokering and paying worker’s compensation or other types of insurance premiums on behalf of participants. • The nature and scope of FMS hinges on the participant direction opportunities that are available under the waiver. Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers, Centers for Medicare & Medicaid Services

12. Waiver Service Rate: State’s Federal Medical Assistance Percentage (FMAP) rate FMS Entities: Any provider that meets qualifications specified in Appendix C-3 Participant Selection: Free choice of any qualified FMS provider Contractual Relationship: Medicaid provider agreement between FMS entity and the state OHCDS: FMS entity may function as an OHCDS by virtue of providing a waiver service (FMS) Administrative Activity Rate: Administrative FFP rate (50%) FMS Entities: Administrative procurement (e.g., RFP) – The number and type of FMS entities may be limited. Participant Selection: Limited to the FMS entities contracted by the state Contractual Relationship: Contract between FMS entity and State OHCDS: FMS entity may not function as an OHCDS Financial Management ServicesPayment Authority Options

13. Information and Assistance in Support of Participant DirectionPurpose and Functions • These supports are made available to participants to help them manage their waiver services. - For example, assistance might be provided to help the participant locate workers who furnish direct supports or in crafting the service plan. • The type and extent of the supports that must be available to participants depends on the nature of the participant direction opportunities provided under the waiver. Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers, Centers for Medicare & Medicaid Services

14. Information and Assistance in Support of Participant DirectionCore Service Definition • Service/function that assists the participant (or the participant’s family or representative, as appropriate) in arranging for, directing and managing services. • Serving as the agent of the participant or family, the service is available to assist in identifying immediate and long-term needs, developing options to meet those needs and accessing identified supports and services. • Practical skills training is offered to enable families and participants to independently direct and manage waiver services. Examples of skills training include providing information on recruiting and hiring personal care workers, managing workers and providing information on effective communication and problem-solving. Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers, Centers for Medicare & Medicaid Services

15. Information and Assistance in Support of Participant DirectionCore Service Definition: (continued) • The service/function includes providing information to ensure that participants understand the responsibilities involved with directing their services. • The extent of the assistance furnished to the participant or family is specified in the service plan. • This service does not duplicate other waiver services, including case management. Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers, Centers for Medicare & Medicaid Services

16. Information and Assistance in Support of Participant DirectionCMS Guidance to States Information may be provided to participant about: • Person-centered planning and how it is applied; • Range and scope of individual choices and options; • Process for changing the plan of care and individual budget; • Grievance process; • Risks and responsibilities of self-direction; • Freedom of choice of providers; • Individual rights; • Reassessment and review schedules; and, • Such other subjects pertinent to the participant and/or family in managing and directing services. Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers, Centers for Medicare & Medicaid Services

17. Information and Assistance in Support of Participant Direction CMS Guidance to States Assistance may be provided to the participant with: • Defining goals, needs and preferences, identifying and accessing services, supports and resources; • Practical skills training (e.g., hiring, managing and terminating workers, problem solving, conflict resolution) • Development of risk management agreements; • Development of an emergency back up plan; • Recognizing and reporting critical events; • Independent advocacy, to assist in filing grievances and complaints when necessary; and, • Other areas related to managing services and supports. Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers, Centers for Medicare & Medicaid Services

18. Information and Assistance in Support of Participant DirectionPayment Authority Options • Case Management Activity - Waiver Service (Case Management) (FMAP Rate)- State Plan Service (Targeted Case Management)- Administrative Activity (Medicaid Personnel or Contracted) (FFP rate %50) • Waiver Service Coverage (FMAP Rate)- One or more distinct waiver services (Supports Broker or Personal Agent)- May be furnished as part of Financial Management Services- State must enroll all qualified providers- Participant has free choice of all qualified providers- May not require participants to receive SB and FMS from same provider • Administrative Activity (FFP Rate %50)- Furnished by Medicaid agency personnel or contracted entities- Considerations similar to payment authority for FMSNote: May combine payment authorities Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers, Centers for Medicare & Medicaid Services

19. West Virginia Personal OptionsOverview • 1915(c) Waiver • Approximately 5,000 Adults with Physical Disabilities and Seniors • Nursing Facility Level of Care • Monthly Budget Based on Level of Care (A,B,C,D) • Waiver Amendment Added Participant Direction • Budget Authority and Employer Authority • Approximately 120 Enrolled Since May, 2007

20. Budget Authority Homemaker Services (within LOC) Homemaker RN Services Case Management Services Homemaker Transportation Services Participant-Directed Goods and Services (Up to $1,000 annually) Employer Authority Homemaker Services West Virginia Personal OptionsOpportunities for Participant Direction

21. West Virginia Personal OptionsCombined F/EA and SB Model • Single Vendor (Public Partnerships, LLC) • Financial Management Services- Fiscal/Employer Agent (F/EA FMS) • Information and Assistance in Support of Participant Direction- Supports Broker (Resource Consultant)- Participant may also purchase case management • Administrative Payment Authority (FMAP %50)- Blended Rate for F/EA and SB Services- Indexed to Level of Care- Not based on units of service

22. Combined F/EA and SB ModelAdvantages • Maximum administrative control • Ease of vendor selection (RFP Process) • Promotes communication (Single point of contact for state; One-stop service delivery for participant) • Promotes collaboration (F/EA and SB are same) • Operational efficiencies (Reduced meetings, shared systems, etc.) • Promotes economies of scale • Training efficiencies • Ease of monitoring single vendor

23. Combined F/EA and SB ModelChallenges • Limits participant choice • Match rate limited to 50% • Possible concerns re: service steering • Limits competition • Potential conflict of interest (If supports broker assesses level of service and financial management rate is tied to level of service)

24. Separate F/EA and SB ModelAdvantages • Maximizes participant choice (Ultimate is personal agent or independent support broker model; 1 to 1) • Opportunity for higher match rate • Competition among vendors may improve quality

25. Separate F/EA and SB ModelChallenges • Costs associated with training, certifying, recertifying and monitoring multiple vendors or providers • Difficulty ensuring communication, cooperation, coordination, and collaboration between and among multiple vendors or providers • Difficult to achieve economies of scale • Difficult to attract vendors or providers to small market segment(s)