BEYOND THE MYTHS: THE VALUE OF USING ARRANGEMENTS THAT SUPPORT SELF-DETERMINATION

Transcription

1 BEYOND THE MYTHS: THE VALUE OF USING ARRANGEMENTS THAT SUPPORT SELF-DETERMINATION Ellen Sugrue Hyman MDCH BH&DDA Self-Determination Development Coordinator

2 SELF-DETERMINATION Self-determination is a set of principles and values that people with disabilities should have the freedom and support have a meaningful life in the community to decide how they live and participate in the community and to control their resources 2

3 PRINCIPLES OF SELF-DETERMINATION Freedom:to plan a real life Authority: to control a limited amount of resources Support: for building a life, connected to one s community Responsibility:for wise use of public $ 3

4 A MEANINGFUL LIFE Meaningful relationships Community membership Having a place of one s own Employment and/or methods of generating income Useful education Health, safety and dignity of risk 4

5 FREEDOM From Self-Determination Policy: The ability for persons, with assistance from supporters (e.g., chosen family and/or friends), to plan a life based on acquiring necessary supports in desirable ways, rather than purchasing a program. 5

6 FREEDOM From Self-Determination Policy: This includes the freedom to choose: Where and with whom one lives Who and how to connect to in one s community The opportunity to contribute in one s own ways The opportunity to develop and pursue personal interests 6

7 AUTHORITY From Self-Determination Policy: AUTHORITY The assurance for a person with a disability to control a certain sum of dollars in order to purchase these supports, with the backing of family, as needed It is the authority to control resources 7

8 SUPPORT Persons don t have to be able to do it all themselves. Most rely on the support of family members, friends and others whom the trust (sometimes called allies or supporters /today we ll call them family ) Can have a representative assist with paperwork or other things 8

9 WHO CAN USE ARRANGEMENTS THAT SUPPORT SELF- DETERMINATION General Directive The person can if The person has the desire to The person has the ability to If the person does not have the ability, friends and family members can perform duties on behalf of the person 9

10 RESPONSIBILITY In Self-Determination, responsibility means: Using public dollars wisely Use authorized funds for services and supports in the plan Being a member of the community 10

11 WHAT SELF-DETERMINATION MEANS Persons want to control who comes into their lives, when, and what they do to assist them When persons choose services and supports, they do not purchase what the system has traditionally or conveniently offered Services and supports are used to create connections, develop real work opportunities and facilitate meaningful community participation 11

12 What are Arrangements that Support Self-Determination? 12

13 THE BASIS OF SELF-DETERMINATION Person-Centered Planning is a right under the Michigan Mental Health Code Self-Determination is contractual requirement between the state and the local agencies that authorize services Available to: persons with developmental disabilities persons with serious mental illness 13

14 THE BASIS OF SELF-DETERMINATION A significant range of flexible tools is available via the use of the additional services in Michigan s 1915(b) waiver Federal support is strong: Olmstead Supreme Court decision Federal Initiatives 14

15 Contractual Requirements PIHPs assure compliance among their network of service providers with the elements of SD policy. That means, PIHP/CMHSPs: Provide people with information about Self-Determination and the support to control and direct services Design planning and service delivery processes to encourage and support individuals to control and direct MH services Ensure PCP processes to develop arrangements that support self-determination Provide a range of options for individual choice and control 15

16 Arrangements that Support Self-Determination A hallmark of self-determination is assuring a person the opportunity to control a fixed sum of dollars which is derived from the person-centered planning process and called an individual budget. The person, together with their allies controls the use of the resources in their individual budget, determining themselves which services and supports they will purchase from whom, and under what circumstances. 16

17 CHOICE AND CONTROL Self Determination builds on choice & control already available within the mental health system: The right to choose providers Person-centered planning process is used to develop the Individual Plan of Services (IPOS) Arrangements that support self-determination are also developed through the PCP process Require agreement on a plan and a budget 17

18 ARRANGEMENTS THAT SUPPORT SELF-DETERMINATION Developed through person-centered planning process Services and supports needed to support person s goals/life Individual Budget to pay for services and supports in plan The arrangements (the way the plan will be implemented) Providers Informal Supports 18

19 SELF-DETERMINATION IS A PARTNERSHIP The Partnership Requires a Written Agreement A Self-Determination Agreement is between the PIHP/CMHSP and the individual using arrangements that support self-determination Authorizes the individual to purchase the services and supports in the IPOS using the funds in the individual budget Describes the rights and responsibilities and is signed by both parties Parties share responsibility for the Medicaid used to support the person 19

20 THE ROLE OF THE PIHP/CMHSP Authorize medically necessary services and supports in an IPOS Authorize an individual budget for the services and supports in the plan Delegate authority for the services and supports in the plan and the budget to the individual Monitor the services and supports in the plan and the budget Provide assistance to the individual as needed 20

21 WHAT IS THE INDIVIDUAL BUDGET? 21

22 THE INDIVIDUAL BUDGET Funds are the assets of the CMHSP Authority over their use is delegated to achieve the plan A written self-determination agreement A copy of the individual budget must be provided to the individual If the budget needs to change, PCP is used 22

23 ESTIMATED COST OF SERVICES VS. BUDGET The purpose of the Estimated Costs of Services is information to make choices The purpose of the Individual Budget is facilitate control over services and supports Choice is greater when person controls $$ and can directly hire providers 23

24 FROM THE PERSON S PERSPECTIVE The Individual Budget must be: Accessible Flexible Portable 24

25 ACCESSIBLE MEANS: The amount and purpose of the budget is known and understood by the person and family The person and family have been fully involved in its development The person and family understands the options (and limitations) for applying the budget The person and family knows how to access funds through the Fiscal Intermediary 25

26 FLEXIBLE MEANS: Flexibility means the ability to: Schedule of the quantity of any given service/support may be varied from day to day Opportunities to redirect savings resulting from lower-than-planned use of funds making up the budget, to purchase other services/supports in the plan 26

27 PORTABLE MEANS: It is possible for the person to use the funds in the individual budget to change providers 27

28 CONTROL OF THE BUDGET Individual may adjust the specific use of funds within the overall amount Unless outside the plan, the individual does not need to obtain permission Adjustments shall occur within a framework that has been agreed to Budget adjustments to be promptly communicated to the PIHP/CMHSP If the adjustment does not serve to accomplish the plan, it cannot be made unless the plan is changed 28

29 PROVIDER QUALIFICATIONS AND OPTIONS 29

30 PROVIDER REQUIREMENTS Persons using arrangements that support self-determination choose their providers Providers must meet provider requirements Provider Qualifications Chart /PIHP- MHSP_Provider_Qualifications_219874_7.pdf 30

31 Provider Qualifications Generally, the provider requirements are: at least 18 years of age; able to prevent transmission of communicable disease; able to communicate expressively and receptively in order to follow individual plan requirements and beneficiary-specific emergency procedures, and to report on activities performed; and in good standing with the law (i.e., not a fugitive from justice, a convicted felon who is either under jurisdiction or whose felony relates to the kind of duty to be performed, or an illegal alien) 31

32 OPTIONS FOR CONTROL OF PROVIDERS Using Arrangements that support SD, Individuals may access any willing, qualified provider, within prudent purchaser constraints A individual may access alternative methods to control and direct support staff, including: Being the employer Accessing an entity that will act as the employer-ofrecord for selected personnel Contract language with existing providers that affords individual control over staff CMHSP direct-employed staff chosen by the individual 32

33 OPTIONS FOR PROVIDERS 1. Employer of Record/Direct Hire 2. Agency with Choice 3. Purchase of Service 33

34 EMPLOYER OF RECORD/DIRECT HIRE Individuals hire, fire and manage their own employees to deliver the services they are eligible for Individuals employees sign employment agreements To ensure Medicaid requirements are met, each of the workers signs a Self-Determination Provider Agreement with the PIHP/CMHSP Individuals agreements are put in writing A fiscal intermediary helps the person manage the individual budget 34

35 AGENCY WITH CHOICE Individuals choose one of the PIHP provider panel agencies to deliver the services they are eligible for but doesn t require the individual to directly hire workers The individual and provider are co-employers of the workers the person uses The provider handles many of the legal and tax employer duties Individual is responsible for managing the workers they hire (and firing them, if necessary) Individual authorizes timesheets and invoices with their signature 35

36 PURCHASE OF SERVICE AGREEMENTS Individuals choose an agency that is not on the PIHP provider panel to provide the services they are eligible for The services must be provided in an integrated community setting not a segregated settling such as a licensed adult foster care home, day activity program or supported employment workshop Individuals agreements are put in writing A fiscal intermediary helps individuals manage their service budget The Provider must meet all credentialing and other requirements for the service being provided 36

37 THE ROLE OF THE FISCAL INTERMEDIARY 37

38 FISCAL INTERMEDIARY (FI) A Fiscal Intermediary is an independent legal entity that acts as assures financial accountability for the funds in a person s Individual Budget and performs essential tasks that support person using arrangements that support self-determination 38

39 WHERE TO FIND INFORMATION ON FISCAL INTERMEDIARIES Self-Determination Policy and Practice Guideline Michigan Medicaid Provider Manual (Fiscal Intermediary Definition) Fiscal Intermediary Technical Requirement Self-Determination Implementation Technical Advisory 39

40 FISCAL INTERMEDIARY TECHNICAL REQUIREMENT Went into effect 10/1/11 Contract attachment Sets forth requirements for Fiscal Intermediaries Clarifies what is required vs. what is best practice 40

41 THE ROLE OF THE PIHP/CMHSP A PIHP/CMHSP shall select and make available qualified third-party entities that may function as fiscal intermediaries to perform employer agent functions and/or provide other support management functions, in order to assist the consumer in selecting, directing and controlling providers of specialty services and supports (SD Guideline) 41

42 THE ROLE OF THE FISCAL INTERMEDIARY The role of the FI is NOT to develop the individual budget or direct how services and supports are used, but to ensure that the payments it makes are correspond with the IPOS and the individual budget 42

43 The Role of the Supports Coordinator/Case Manager Review monthly budget reports from FI Track over/underutilization of budget Discuss over/underutilization with participant Intervene, when necessary: Convene person-centered planning process Recommend steps to address situation Terminate SD Agreement 43

44 THE ROLE OF THE INDIVIDUAL Provide all necessary information regarding all providers of services and supports and ensure that all required documentation and written agreements are in place Assure that each service provider retained by meets the provider qualifications Provide the fiscal intermediary or agency with choice with necessary authorization and documentation (such as timesheets and invoices) to support use of the funds in the individual budget 44

45 REQUIRED FISCAL INTERMEDIARY FUNCTIONS Financial Accountability Functions FI Technical Requirement (pages 17-18) Employer Agent functions FI Technical Requirement (pages 18-19) 45

46 FINANCIAL ACCOUNTABILITY FUNCTIONS Have a mechanism to crosscheck invoices submitted and approved by the individual with authorized services and supports in the IPOS and individual budget Have a procedure for handling invoices for unauthorized services and support Have a system in place for identifying potential over- and under-expenditures 46

47 FINANCIAL ACCOUNTABILITY FUNCTIONS Minimum Budget Monitoring Requirements Provide monthly financial status reports to the supports coordinator or case manager and the individual by no later than 15 days after the end of month Contact the supports coordinator or case manager by phone or in the case of an over-expenditure of 10 percent in one month prior to making payment for that expenditure Contact the supports coordinator or case manager by phone or in the case of under-expenditure of the pro rata share of the individual budget for the month that indicates that the individual is not receiving the services and supported in the IPOS 47

48 EMPLOYER AGENT FUNCTIONS For all individuals directly employing workers, entities providing FI services must facilitate the employment of service workers Issue payroll payments to directly employed workers for authorized services and supports that comport with the individual budget or have approval from the PIHP/CMHSP for payment Withhold income, Social Security, and Medicare taxes from payroll payments and make payments to the appropriate authorities for taxes withheld 48

49 MYTHS ABOUT SELF- DETERMINATION 49

50 MYTH PIHP/CMHSPs will be held liable for bad care or no care 50

51 TRUTH In Self-Determination, the PIHP/CHMSP is not responsible for the work of a worker hired by a person using services because: Worker met provider qualifications (including any requirements regarding criminal backgrounds) Worker was selected and hired by employer (employee agreement is between the employer and employee) However, if the PIHP/CMHSP discovers a problem through monitoring, it has a duty to intervene 51

52 Ways to Intervene Duty to intervene when you know that services are not being provided Methods Talk with person (determine the reason) Convene person-centered planning process Work with person to change providers Add steps/providers to Backup Plan Terminate Self-Determination Agreement 52

53 PROBLEM-SOLVING PCP is the best way to resolve issues and reach a solution The person might need additional support, training or other assistance in the arrangement to support self determination Every CMHSP has a local dispute resolution and mediation process to help resolving disputes about self determination 53

54 Responsibilities and Monitoring In Arrangements that support self-determination, the responsibility for obtaining services and supports is delegated to the person PIHP/CMHSP is responsible for monitoring the services and supports The PIHP/CMHSP will only be held responsible if the it knew or should have known about bad care or lack of care and did not do anything about it 54

55 Monitoring Service Delivery Methods for Monitoring Service Delivery Clear information and guidance to person Face to face contacts Phone calls and other 55 contacts FI monthly budget reports Individual and Systemwide back-up plans 55

56 MYTH New FLSA Rules on Minimum Wage and Overtime for Home Care Workers Will Change Self- Determination 56

57 TRUTH New Rules Will NOT cause big changes Michigan already requires minimum wage and overtime for home care workers Delayed enforcement of rule No enforcement first six months (January 1- June 30, 2015) Limited enforcement July 1-December 31,

58 New FLSA Rules Biggest Concerns PIHP/CMHSPs need to review policies and practices to ensure that they are AVOIDING joint employment See Handout 58

59 Avoiding Joint Employment (Steps PIHP/CMHSPs should take) Setting a range of reimbursement rates for each service and letting the employer set the wage rate; Limiting the provider qualifications and training requirements for workers to MDCH requirements; Permitting employers to recruit, interview and hire any provider that meets basic qualifications; and Staying out of the scheduling, supervision and management of workers. 59

60 New FLSA Rules Biggest Concerns The final rule narrows the home care exemption from minimum wage, overtime, and recordkeeping to employees who provide: Companionship Services (Fellowship and Protection) Care can be can be incidental to fellowship and protection if it does not exceed 20% of hours worked. Cannot be medically related services or for the benefit of other household members Live-in Domestic Services (private home) (Permanent No other residence) or (Extended- works and sleeps at residence 5 nights a week (120 hours) or 5 consecutive nights) Exemptions only available when the worker is directly and solely employed by a consumer or the family/household member of the consumer 60

61 MYTH Using Self-Determination means that you don t have to follow Medicaid requirements 61

62 Truth Medicaid requirements apply to all services and supports obtained through arrangements that support selfdetermination No exceptions (No cars, No Trips to Disney) People using arrangements need to understand this and be informed what they need to do to comply with requirements 62

63 Medicaid Fraud There s more fear than fraud Fraud risk is not greater in selfdetermination Education of people using services, allies and workers is key PIHP/CMHSP can only be held liable if it knows about fraud and fails to intervene 63

64 Medicaid Fraud Proactive strategies for addressing Medicaid Fraud: Clearly explain roles and responsibilities Information and training Effective informal supports (family, friends, others) Establish effective communication paths Monitoring Addressed through PCP Individualized 64

65 MYTH There is not way to prevent a person from overutilization of services 65

66 TRUTH Overutilization of services is prevented and avoided through education and monitoring 66

67 Informing about Budget Limitations People using services should be informed and supported on the use of the individual budget Self-Determination Agreement Easy-to-Understand IPOS and Budget Timely Monthly Budget Report (from Fiscal Intermediary) Persons using services must understand that they are ultimately responsible for services and supports that they approve that are not authorized in their individual budgets 67

68 Budget Monitoring Must provide information on the use of the budget to the person using services Monitor monthly budget reports Flag over/under expenditures Intervene when there is significant overspending (understand the cause) If intervention fails, the PIHP/CMHSP can terminate the self-determination agreement 68

69 Informing about Budget Limitations Employees should be informed in the employment agreements on the limitations of funding and the consequences of Medicaid fraud 69

70 Monitoring by Fiscal Intermediary Not a Checking Writing Service The Fiscal Intermediary is a fiscal agent of the PIHP/CMHSP to ensure accountability of public funds Fiscal Intermediary Technical Requirement Contract Attachment P

71 Monitoring by Fiscal Intermediary Fiscal Intermediaries must have a system to cross-check approved invoices and timesheet against authorizations in individual budget But what about requirements that workers be paid for hours worked EMPLOYER is responsible for paying for hours they approve that are not authorized by the PIHP/CHMSP 71

72 MYTH The PIHP/CMHSP does not have the right to interfere with arrangements that support self-determination 72

73 TRUTH The PIHP/CMHSP has ultimate responsibility for the provision and monitoring of mental health services and supports If services are not being provided or if a person s health or welfare are at risk, the PIHP/CMHSP not only can intervene, it has a duty to intervene 73

74 Ways to Intervene Discuss issue with the person Convene the person-centered planning process Determine that a bad provider is not qualified Terminate the self-determination agreement 74

75 Terminating an SD Agreement There is no absolute right to arrangements that support self-determination, especially when: A person s health and welfare is at risk Rules and regulations regarding the use of Medicaid and public funds are not being followed Denial of Termination of self-determination is not a Medicaid fair hearing issue 75

76 Always Remember Arrangements that Support Self-Determination exist within the framework of publicly-funded and Medicaid-funded services All of the responsibilities regarding the use of Medicaid funds still apply There is no absolute right to arrangements that support self-determination Other concerns aside, err on giving people opportunity to try with proper support and monitoring in place 76

77 FOR MORE INFORMATION 77

78 HELPFUL RESOURCES Self-Determination Guidance Michigan Partners for Freedom 78

79 Self-Determination Guidance Self-Determination Policy and Practice Guideline October 1, 2012 The policy and practice guideline includes all MDCH BH&DDA requirements for implementation of arrangements that support self-determination. Self-Determination Technical Advisory March 1, 2013 (Replaces the Choice Voucher System Technical Advisory). This Technical Advisory includes MDCH BH&DDA's best practice recommendations on implementing arrangements that support self-determination including direct employment and agency with choice options and guidance on development of individual budgets. A set of prototype agreements is included. SD Frequently Asked Questions March 1, 2013 This document is a compendium of questions relating to self-determination from PIHPs and CMHSPs and answers from MDCH BH&DDA. While it may reference requirements from the Self-Determination Policy and Practice Guideline, this document should be considered best practice recommendation. How Self-Determination Works May 1, 2013 This is an easy-to-read Q&A on how to use arrangements that support selfdetermination for people who use mental health services and their families and friends. 79

80 For More Information Ellen Sugrue Hyman MDCH BH&DDA Self-Determination Coordinator 80