Developing Individual Budgets for Use in Self-Determination in the Michigan Mental Health System

1. Developing Individual Budgets for Use in Self-Determination in the Michigan Mental Health System Self-Determination Leadership Development Seminar September 22, 2009

2. Individual Budget Definition From the Self-Determination Policy, the budget is: • A fixed allocation of public mental health funds • Derived from the costs of needed services & supports • May also include other public resources to be accessed and integrated through the CMHSP • Denoted in dollar terms as well as services • Agreed to by the individual and the CMHSP as the necessary cost of services and supports needed to accomplish a consumer’s plan of services/supports.

3. Individual Budget In accordance with the Self-Determination Policy: • The budget is expected or estimated costs of a concrete approach to accomplishing the consumer’s plan (Item II-C) • Developed in conjunction with development of a plan of specialty mental health services and supports, using a person-centered planning process (II-A) • The amount of the budget shall be formally agreed to by both the consumer and the CMHSP before it may be authorized for use (II-D)

4. MDCH EXPECTATION • 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 • If the individual does not know what the budgeted amount is, and what it is intended for • It ain’t self-determination • An individual budget must be sufficient for the consumer to accomplish the goals and outcomes contained in their plan of services and supports • The pathways to achieving those may be varied

5. Putting the Individual Budget Development Process into Context • We live & work in a world of limited resources - - • For agency supports coordinators and managers, gatekeeping is an expected role • Somewhere between the organization’s need to conserve resources and the individual’s desire for their own share is a middle ground • How do we get there? • What is sufficient? • How do we assure fairness? • How do we empower participants? • When the individual knows what s/he has to work with, and the basis for that amount, it is rather easy to learn how to effect control, eventually

6. Goal: To Establish 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 from others being in charge of one’s life course, to personal self-determination • The specific methods to assure direct participant choice of and control over providers are not so important • But providing authority for choosing and influencing provider behavior is the purpose of the mechanics involving arrangements that support self-determination • An individual budget, therefore, is a central piece of the machinery of those arrangements • So is the manner in which the individual is supported to apply the individual budget

7. From TheParticipant’s Perspective • The budget must be: Accessible Flexible Portable

8. Accessible • The amount and purpose of the budget is known and understood by the participant • The participant and his or her allies have been fully involved in its development • The participant understands the options (and limitations) for applying the budget • The participant knows has been oriented on how to use those funds and provided with a connection to where the funds are lodged • Ongoing information is provided to the participant and chosen allies on the status of the budget (monthly)

9. Flexible • Options are provided for modifying the budget components within the overall amount, including: • Planning is flexible in accordance with how a person chooses to live day to day • Scheduling the amounts of specific service/support may vary day to day, week to week • The actual use of a given service/support may be varied, in the end, in comparison with the original plan • i.e. the participant may adjust their own service “dose” • There are opportunities to redirect savings that may result from lower-than-planned use of services/supports, to other more preferable services/supports options • May be preliminarily authorized on a contingency basis in the plan, or • Plans may be adjusted later on • Communication needs to be ongoing

10. Portable • It must be possible for the participant to manipulate and transfer budgeted resources, from one provider arrangement to another. • Participant must be permitted change fiscal intermediaries, with in a framework defined by the PIHP/CMSHP • Budget savings can be maintained within a reasonable framework

11. Informed of Options Participants must be informed of the options for flexibility and portability • Participants must be provided with guidance about the types of variations they may initiate and the types that will require prior approval • Including expectations that these must be communicated to the PIHP/CMHSP • Informed in writing • A how-to guide • Ongoing guidance is easily accessible • A Specialist • Peers • Fiscal intermediary

12. Two Different Approaches for Determining Individual Budget Amounts • Prospective Method • Benefit amount is determined in advance of PCP • Objective assessment of need determines IB; • Participant determines spending plan, services, supports & implementation strategy • Retrospective Method • Benefit amount is determined in response to PCP • Participant Identifies needs within PCP • Agency (alone or in concert with participant) determines benefit amount, services & supports • Participant determines spending plan, & implementation strategy

13. Prospective/Retrospective Budgeting Participant Enters System Assessment completed using PCP principles Retrospective Budgeting Prospective Budgeting 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

14. Retrospective vs Prospective • Michigan uses a retrospective method to determine the amount of an individual budget • First, the plan of services and supports is developed • Then, the amount of the budget is determined based upon the costs of services outlined in the plan • A prospective method typically involves using assessment 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 • In Michigan, use of an assessment to determine services authorization may not be substituted for the person-centered planning process • The prospective method involves a budget cap; we do not cap budgets on the front end • But limits on each individual budget developed are going to come form somewhere • In the end, the agreement by the participant is to implement the plan within the overall budget amount

15. Per CMS:The Individual Budget • Value ($) of services & supports under the control & direction of the participant • May include Medicaid & Non-Medicaid services/supports but must have clear audit trail of Medicaid $

16. CMS EXPECTS STATES TO ADDRESS THESE ISSUES REGARDING IB • Describes the method for calculating based on reliable costs or services utilization; • Developed using a consistent methodology for all involved participants; • Reviewed & monitored according to a specified method & frequency; • Provides participant ability to move money around; • Methodology is open to public inspection; • Informs participant of amount that is authorized to be self-directed; • Defines a process for making adjustments & informs participant; • Provides procedures to evaluate over & under expenditures; • Provides prompt mechanisms to adjust funding in response to individual situations;

17. BUDGET Development 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

18. Developing the Plan • Person-centered planning • Involves the person’s whole life • Addresses health, welfare and opportunity for integration, participation and productive activity • Services needed are authorized with equity in mind • Service authorizations are provided in specific form with respect to the amount, duration and scope of each service • Bringing in the cost issues too soon will corrupt the process of determining and fairly meeting individual needs

19. The Budget • Person-centered planning • About the person’s whole life (NOT just the services to be obtained through the MH system) • Planning a budget takes into account the person’s whole resource picture • Entitlements • Earnings • In-kind contributions from allies • CMHSP-provided resources • Saving money is not a primary goal • Ratcheting down on opportunity or working outside of fairness and equity is not acceptable • Obtaining better value is ongoing • Examining costs versus outcomes • Facilitating a learning process whereby new options for achieving outcomes are at the heart of improving value

20. Calculating the Budget Amount In simplest case: • Services authorized are at a static, known level, and the person is not seeking a change • Services are to be provided from among a group of known providers with known rates • The budget is rather straightforward • Choice and control may be contracted through the CMHSP • But, there is a defined individual budget, the person has participated in its development, has agreed to the amount, and may access the budget, based upon agreements reached in the planning process, using a fiscal intermediary

21. SUPPORTS PLANNING GRID

22. Calculating the Individual Budget More complicated • The person is moving into a role that is new (e.g. independent living) • The services are to be consumer-controlled via direct contracts that the consumer will negotiate • Providers are not looking so “traditional” • E.g. individual personal assistance providers rather than agency-provided Pas • Rates to be authorized do not include the same cost factors • Innovative provider arrangements are sought • Incentivised approaches to obtaining work • Companionship models that provide some of the personal assistance • Peer support services • Rates are different

23. Rates for Services • They may not be excessive • They must be sufficient for the participant to acquire qualified and capable providers • Wage rates • Must be sufficient • Necessary add-ons • Worker’s compensation • Training needs • Health care if possible • Guidance must be provided to the participant regarding the range of applicable rates • Maximum amounts that the consumer may spend to pay specific providers may be specified by the CMHSP (III-B-3-e)

24. Once the Budget is Agreed To • There shall be a written agreement between the consumer and the PIHP/CMHSP delineating the responsibilities and authority of each party • The agreement shall include a copy of the participant’s plan and individual budget • The directions and assistance necessary for the participant to properly use the budget shall be provided to the consumer in writing when the agreement is finalized. (II-E-2)

25. New B -3 OPTION“Goods & Services” • Goods and Services are available only to individuals participating in arrangements in self-determination whose Individual Budget is lodged with a fiscal intermediary. Projected savings from the use of the Individual Budget can be used to acquire goods and services that (1) increase independence, facilitate productivity, or promote community inclusion and (2) substitute for human assistance (such as personal care in the Medicaid State Plan and community living supports and other one-to-one support described in B3 Alternative Service definitions) to the extent that Individual Budget expenditures would otherwise be made for the human assistance.

26. New B -3 OPTION “Goods & Services” • The purpose of the Goods and Services is to promote individual control over and flexible use of the individual budget by the individual using arrangements that support self-determination, to promote savings and the prudent use of Medicaid funds, and to facilitate creative use of funds to accomplish the goals identified in the individual plan of services through achieving better value or an improved outcome. • A Goods and Services item must be identified using a person-centered planning process, meet medical necessity criteria, and documented in the individual plan of services. Goods and Services may not be used to acquire goods or services that are prohibited by federal or state laws or regulations.