Implementing Self-directed Services Under MLTSS
September 10, 2014
3:00 – 4:30 pm EDT
Susan Flanagan
Principal
Westchester Consulting Group
sflanagan@westchesterconsulting.com
Suzanne Crisp
Director of Program Design & Implementation
NRCPDS
suzanne.crisp@bc.edu
Purpose of Webinar
• Provide an overview of implementing
self-directed services under a managed
long-term services and supports
(MLTSS) system.
• Discuss the challenges and lessons
learned, promising practices and
strategies for successful implementation
and monitoring.
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Purpose of Webinar (cont’d)
• Provide opportunities for participants to:
—Talk to each other!!
—Hear directly from a State agency representative
about challenges and successful strategies in
implementing self-directed services under MLTSS.
—Learn about available resources.
—Share and discuss ideas for adopting and/or
adapting successful strategies for implementation
and monitoring services and MCEs’ performance.
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Learning Objectives
• Participants will understand the:
- Key components of self-directed services and the
MLTSS delivery model,
- States that have implemented and monitored the
provision of self-directed services under MLTSS, and
how one State accomplished this, and
- Benefits, challenges, lessons learned and successful
strategies for implementing self-directed services
under MLTSS.
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Who is on the call today?
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What is Self Direction?
• Self Direction (also known as consumer or
participant direction)
- Is a HCBS delivery model where individuals and their
representatives, when applicable, have decisionmaking authority and take direct responsibility for
managing their services with the assistance of selfdirected supports.
- Represents a paradigm shift in HCBS delivery –
transferring decision-making and managerial authority
from providers to individuals and families while
providing them with supports.
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What are Self-directed Services?
• Promote choice and control for individuals
and families over their LTSS and the direct
service workers who provide them.
• In 2013, the NRCPDS survey of
participant-directed service programs
identified 269 programs operating in 50
states serving ~ 840,000 people
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What are Self-directed Services?(cont’d)
• They liberate a nontraditional direct
service workforce of relatives and
friends.
-
Many take advantage of the opportunity to hire
relatives (i.e., 50 percent of participants in the RWJ
Cash and Counseling Demonstration (Mahoney,
2005) and 72 percent of CA IHHS Program
participants receiving Medicaid State Plan
personal care services (CA DHHS, 2013)).
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Options for Providing Self-directed
Services Under Medicaid
• §1915(i) HCBS SPA
• §1915(k) Community First Choice SPA
• §1915(j) Self-directed PAS SPA (overlies other
authorities)
• §1915(c) HCBS and §1115 Demonstration Waivers
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Common Characteristics of Selfdirected Services
•
•
•
•
Person-centered planning process
Flexible service plan
Individual budget
Information & assistance (I&A) in
support of self-direction
• Financial management services (FMS)
• Quality assurance and improvement
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Key Domains of Self-directed Services
• Degree of flexibility
Employer Authority. Is the individual/ representative
allowed to act as a common law or joint employer of
his/her direct service workers and manage or
actively participate in performing employer tasks?
Budget Authority. Is the individual/representative
allowed to develop and manage an individual budget
of their LTSS and purchase individual-directed
goods and services?
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Key Domains of Self-directed
Services (cont’d)
• Supports available
- Information and Assistance (I&A)
- Financial Management Services (FMS)
• Self-directed service implementation
Developing FMS and I&A standards
- Developing performance-based contracts and/or
Medicaid provider certification requirements
-
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Key Domains of Self-directed
Services (cont’d)
- Ensuring self-directed service program is in
compliance with 9/17/13 DoL FLSA Rule for
Companionship and Live-in Exemptions to
Domestic Service including determining
state’s status as a third party joint-employer
- Implementing FMS & I&A Readiness Review
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Key Domains of Self-directed
Services (cont’d)
– Monitoring quality of:
• Self-directed service delivery
• FMS and I&A performance
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Key Domains of Self-directed
Services (cont’d)
-
Tools
• Agreed upon procedures reviews
• Reporting
• Benchmarks
• Assessing user experience and satisfaction
(surveys)
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Processing and Discussion
• What is your biggest insight about what you just
heard?
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What is Managed LTSS?
• Delivery system where States contract
with managed care entities (MCE) defined
at 42 CFR 438.2 to provide LTSS
generally through a capitated monthly per
member payment
• MCE manages LTSS through degrees of
financial risks for members
• May be HCBS and/or institutional care
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Why Do States Implement MLTSS
Delivery Systems?
• Looking for health care cost controls
• Moving towards integrated, coordinated
care – reduce fragmentation in service
delivery
• Focus on transition planning
– Enrollees transitioning from institutions to
HCBS
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Options for Implementing MLTSS
• Medicaid Authorities Vary
–
–
–
–
–
§1915(b)/(c) (FL, WI, MI, MN - SCP, NM*)
§1115(a) (AZ, HI, NM*, TN & TX)
§1915(a)/(c) (MA)(MN SHO)
§1932(a) (WA)
§1115(a)/1915(c) – (KS)
*NM transitioned its §1915b/c to §1115(a) authority.
*MN is transitioning its §1915(b)/(c) to §1115(a) authority.
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CMS’ Position on Provision of Selfdirected Services Under MLTSS
• CMS supports self-direction (SD) in both fee-forservice & managed care service delivery
systems implemented under §1115(a) and
§1915(b) (Most recently published in May 2013)
States that offer self-directed services … are expected to
continue….
States that do not currently offer self-directed services… should
consider providing the opportunity…within a MLTSS program.
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21 States Had MLTSS Programs as of May 2014,
Up From 8 in 2004 (Truven Health Analytics)
MLTSS implemented 1989-2004
MLTSS implemented 2005-May 2014
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How Is Self Direction Beneficial to
MCEs?
• Positive response to advocates and
member requests for more flexibility
• Use of service coordination and efficiency
strategies have the potential to provide
more services for the same dollars
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Selected Studies on Implementing
Self-directed Services Under MLTSS
• ASPE -Truven Five State Study (2013)
– AZ, MA, NM, TN & TX
• Mathematica/CMS Report: Selected
Provisions from Integrated Care RFPs and
Contracts: Participant Direction (2014)
– ASPE Study States and FL, HI, KS, MI, MN, WA &
WI
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Study Methodology
• Both studies use a qualitative case study
method
• ASPE-Truven Five State Study
– Reviewed
• Request for Proposals
• Contracts
• Policy & Procedures
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Study Methodology (cont’d)
– Interviewed
• State Officials
• Managed Care Entities (MCE) Administration & Service
Coordinators
• FMS Agencies
• Advocacy Groups
• Mathematica Study
– Reviewed
• Request for Proposals
• Contracts
• Policy & Procedures
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Findings from Selected Studies
• Findings Include:
– Number of individuals who self-direct in MCEs –
77,500
– All States reviewed include people with disabilities
and elders
– Most “carve-out” intellectual and developmental
disabilities
– All but one State required the MCE to introduce the
self direction option
– All but one State include the essential elements of
self direction in their contract with the MCE
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Findings from Selected Studies (cont’d)
– Wide variation in:
• Number of members enrolled
• Training for MCE service coordinators
• Quality assurance/improvement, oversight, and monitoring
– Some States rely on contracts to manage selfdirected services; others use policy & procedures
– Four States offer employer and budget authority
– Two States have recently dropped budget authority
– In one State budget authority is limited to employment
related issues
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Findings from Selected Studies (cont’d)
- Information & Assistance
• Internal to MCE or subcontracted
• One State created a new function to manage the day-to-day
supports provided to members and coordinate activity with
MCE case manager and FMS
• Training is conducted by the MCE often with help from the
Aging and Disability Network
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Findings from Selected Studies (cont’d)
- Most States require their final approval of FMS
vendors used
•
•
•
States may delegate the selection and legal arrangement
between the MCE and FMS
States may arrange for FMS vendors directly
States may execute the legal agreement or enter into a 3way contract between the State, the MCE and the FMS
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Findings from Selected Studies (cont’d)
- The number of FMS vendors used by a State varied
-
-
from 1 to 400
Five States use Vendor F/EA FMS
Six States use both Vendor F/EA FMS and Agency
with Choice
None of the States use the Government F/EA FMS
Growing trend to offer both FMS models within a
State
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Observations
• States play a major role in implementing
self-direction and MLTSS.
• Commitment to self direction is related to
the State’s expectations and guidance.
• Member introduction & orientation, and ongoing support of self direction can be timeconsuming for service coordinators and
often is conducted in an inconsistent
manner.
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Observations (cont’d)
• How self direction is presented is critical to
a member’s understanding and willingness
to use this service delivery option.
• “Less is more” when implementing FMS so
State can monitor performance of FMS
vendors in an effective and timely manner.
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Observations (cont’d)
• It is unclear how committed MCEs are and
their level of understanding of self
direction.
• Standardized training for MCE service
coordinators is key for successful
recruitment and retention of members
using self direction.
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Observations (cont’d)
• Specific language/standards for self
direction included in State policies and
procedures may be more effective in
implementing self direction under MLTSS
than embedding self direction language in
administrative contracts with MCEs
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Processing and Discussion
• What is your biggest insight about what you just
heard?
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State Successful Strategy Presenter
• Michelle Morse Jernigan, Deputy, LTSS
Quality Administration, TN Dept of Finance
and Administration, Bureau of TennCare
Michelle.m.jernigan@tn.gov
(615) 507-6528
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What Did We Do?
• Tennessee implemented managed care
in1994.
– Mandate that all TennCare members enroll in
managed care
– Coordinated all physical and behavioral health needs
– In 2010, the State implemented MLTSS - CHOICES
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What Did We Do? (cont’d)
• Implementation of CHOICES
– “Carved in” LTSS
• Nursing facility care and HCBS
• Elders age 65+ and adults age 21+ with physical
disability
– Added Community Based Residential Alternatives to
HCBS package
– Added consumer direction option
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What Did We Do? (cont’d)
• Consumer Directed Option
– Vendor Fiscal/Employer Agent (VF/EA) Financial
Management Service (FMS) model used
– 1,177 participants (as of 5/1/14)
– 1,459 consumer-directed workers
• Total CHOICES enrollment (as of 5/1/14)
– NF = 18,170 (59%)
– HCBS = 12,740 (41%)
– ~ 9% of total HCBS members self-directing
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Challenges & Lessons Learned
•
•
Challenge: Enrolling elders and persons
with physical disabilities took significantly
longer than for individuals with
intellectual/ developmental disabilities
Lesson Learned: Enrollment differs by
population and needs to be taken into
consideration when developing
policies and procedures.
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Challenges & Lessons Learned (cont’d)
• Challenge: Elders and persons with
physical disabilities were confused about
the role of the Supports Broker compared
with the role of their Care Coordinator.
• Lesson Learned: Need to lay out the roles
and responsibilities clearly and compared
to other care management roles.
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Challenges & Lessons Learned (cont’d)
• Challenge: Elders and persons with
physical disabilities in CD didn’t feel they
had to comply with State’s Electronic Visit
Verification(EVV)System – wanted more
flexibility in reporting workers’ time on job.
• Lesson Learned: State needed to build
more flexibility into the EVVS for reporting
workers’ time on job.
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Promising Practices
• Prescriptive requirements
• Contractor Risk Agreement (CRA)
– MFP incentive
• consumer direction enrollment benchmark
– Care Coordinator
• Introduces consumer direction at enrollment and annually
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Promising Practices (cont’d)
• VF/EA FMS contract
– VF/EA FMS organization tasks
• Enrollment and payroll management
• Required to contract with the managed care entities (MCEs)
– Supports Broker tasks
• Train members
• Assist with completion of all onboarding tasks (enrollment)
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Promising Practices (cont’d)
• Monitoring provision of services
– Electronic visit verification
– Care coordinator required contacts
• Monitoring quality of care
– Customer satisfaction surveys
• TennCare and VF/EA FMS
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Key Outcomes
• Increased quality of life and care for
members
• 95% prefer choosing own workers
• 97% like being in charge of directing their services
• 91% think their life and health are better since
using consumer-directed services
• 99% of services provided when needed
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Recommendations
• Claims process between managed care
organizations and VF/EA FMS entity
– Implement tracking mechanism immediately
• VF/EA FMS Request for Proposal Process
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Recommendations
(cont’d)
• VF/EA FMS Readiness Review
• Member/Representative Satisfaction
Surveys
– Use results
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Processing and Discussion
• What is your biggest insight about what you just
heard?
• What do you could do in your State/program that
is similar?
• What do think the challenges might be to
implementing self-directed services under a
MLTSS delivery system in your State/program?
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Selected Resources
• ASPE -Truven Five State Study:
https://bcweb.bc.edu/libtools/details.php?entryid=417
• Financial Management Services and Managed LongTerm Services:
• https://bcweb.bc.edu/libtools/details.php?entryid=377
• Mathematica/CMS Report: Selected Provisions from
Integrated Care RFPs and Contracts: Participant
Direction: http://www.chcs.org/usr_doc/RFP_Toolkit__Participant_Direction_4_28_14_(2).pdf
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HCBS TA Available
• Determining what authority will best meet your
objectives.
• Providing guidance on major features of §1915(i),
including developing needs-based criteria.
• Providing guidance on integrating §1915(i) with other
services, such as §1915(c) waiver services.
• Providing guidance on major features under a §1915(c)
or §1115 waiver or §1915(i), (j) or (k) SPA, including
implementing self-directed services and developing
person-centered plans & budgets.
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HCBS TA Available
(cont’d)
• Providing guidance on implementing self-directed
services under MLTSS.
• Providing clarification and assistance with the CMS
waiver and state plan amendment application processes.
• Identifying and addressing common barriers to
implementation.
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Examples of Topics for HCBS-TA
• HCBS under §1915(i), (j) and (k) SPAs and §1915(c)
and § 1115(a) waivers
• Self-directed Services under §1915(i) (j) and (k) SPAs
and §1915(c) and §1115(a) waivers
• §1915(k) Community First Choice Option SPA
• Person-centered Philosophy and Systems
• Person-centered Planning
• Individual Budgeting
• Need Assessment
• Positive Behavioral Supports
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Examples of Topics for HCBS-TA
(cont’d)
•
•
•
•
•
Supported Employment
Community Integration
Rate Setting Methodologies
Managed Care including Managed LTSS
Other Areas as Needed by States
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Where to Find Help
• To request TA:
http://www.hcbs-ta.org/request.aspx
• For additional information:
http://www.hcbs-ta.org
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