Self-Direction in Mental Health: from Ideas to Medicaid Funding Strategies that Support Self-Direction for Persons with Mental Illness

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Self-Direction in Mental Health from Ideas to
Medicaid Funding Strategies that Support
Self-Direction for Persons with Mental
Illness Marguerite Schervish, JD Health
Insurance Specialist Centers for Medicare
Medicaid Services Center for Medicaid and State
Operations Disabled and Elderly Health Programs
Group

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2001 New Freedom Initiative
A government-wide framework for presenting elders
people with disabilities with necessary
supports to live fully participate in community
life. www.cms.hhs.gov/newfreedom

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CMS Response to NFI

• Development of Independence Plus Initiative and
  templates
• Builds on the experience research of the
  Self-Determination Cash Counseling programs
• Provides a framework for states to submit
  1915(c) waivers or 1115 demonstrations with
  self-direction components
• Requires supports protections to safeguard
  the health welfare of participants
• www.cms.hhs.gov/independenceplus

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Research Results

• Cash Counseling
• Mathematica Findings
• Increased satisfaction
• Lower incidence of caregiver neglect
• Fewer unmet needs
• Higher levels of satisfaction with overall care
  quality of life

• Self-Determination
• The Center for Outcome Analysis Findings
• Increased control over their lives
• Improved qualities of life
• Costs either decreased or remained stable

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CMS Leadership

• Mark B. McClellan, MD, Ph.D,
• Administrator CMS
• Because the concept of allowing
• more people to have more personal control over
  their lives improves satisfaction may reduce
  costs, we intend to keep taking steps to remove
  barriers, real or perceived.
• (December 2004 Press Release)

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CMS Leadership

• Mark B. McClellan, MD, Ph.D,
• Administrator CMS
• The Independence Plus programs allow participants
  to design a package of individualized supports,
  identify attain personal goals, supervise
  pay their caregivers.
• (Hearing on Long-Term Care and Medicaid Better
  Quality and Sustainability by Giving More Control
  to People with a Disability Subcommittee on
  Health of the House Committee on Energy and
  Commerce April 27, 2005)

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CMS Leadership

• Mark B. McClellan, MD, Ph.D,
• Administrator CMS
• At the just completed Home Community Based
  Waiver Services Conference, Dr. McClellan
  described the Independence Plus program as a CMS
  flagship program declared support for
  creative strategies in self-directed care.
• (May 15, 2005)

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CMS Definition of Self-Direction

• A state Medicaid program that presents
  individuals with decision-making authority over
  workers who provide services,
  a participant-managed budget or
  both.

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IP Person-Centered Planning

• A process, directed by the participant, with
  assistance as needed from a representative of the
  participants choosing, intended to identify
  strengths,
• capacities, preferences, needs desired outcomes
• Includes planning for Psychiatric Advance
  Directives for persons with mental illness

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IP The Individual Budget

• Total dollar value of services supports
• under the control direction of the participant
• May include Medicaid non-Medicaid services
  supports but must have clear audit trail
• Developed using person-centered planning process
  consistent methodology to calculate amount
• Participant knows how it can be changed

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IP Person-Centered Planning

• A system of activities to assist participants
• to develop, implement manage the support
  services identified in their budget such as
• - Information
• - Assistance with employment-related
  responsibilities
• - Locating accessing community services,
  training, etc.

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IP Quality Assurance Quality Improvement

• The QA/QI model builds on the existing
  foundation, formally introduced under the CMS
  Quality Framework
• - Quality is built into the programs design
• - Discovery
• - Remediation
• - Continuous improvement
• www.cms.hhs.gov/medicaid/waivers/frameworkmatrix.a
  sp

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Approved IP Waivers Demonstrations(as of
4/14/05)

• Section 1915 (c) waiver programs
• NH, SC, LA, NC, MD, DE, CT
• Section 1115 demonstration programs
• AR, FL, CA, NJ
• Concurrent Section 1915 (b)/(c)
• NC

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Medicaid Funding Options

• State Plan Services
• Section 1115 Demonstrations
• Section 1915 (c) Waivers
• Section 1915 (b) Waivers
• Concurrent Section 1915 (b)/(c) Waivers
• Real Choice Systems Change Grants
• Other Grant Programs

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State Plan Services

• Mandatory core services
• Inpatient hospital services (other than in
  institution for mental diseases (IMDs))
• Outpatient hospital services including rural
  health clinics
• Other lab X-ray services
• Services provided by certified pediatric
  family nurse practitioners

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State Plan Services

• Mandatory core services
• EPSDT for children under age 21
• Physicians services
• Medical surgical services of a dentist
• Family planning services supplies
• Home health services for beneficiaries who are
  entitled to nursing facility services under
  states Medicaid Plan

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State Plan Services

• Mandatory core services
• Medical supplies
• Nurse midwife services
• Pregnancy related services
• 60-day post-partum pregnancy related services

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State Plan Services

• Optional State Plan Services
• Rehabilitative Services very broad in scope
• Any medical or remedial services for maximum
  reduction of physical or mental disability
  restoration of a recipient to his best possible
  functional level
• Recommended by physician or other licensed
  practitioner of the healing arts

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State Plan Services (continued)

• State must certify or license the providers to
  ensure they are professionals qualified to
  provide peer supports
• Can include specialty services of relevance to
  persons with mental illness
• Case management/targeted case management
• Psychosocial rehabilitation
• Assertive Community Treatment
• Peer Support
• Outpatient therapy

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State Plan Services

• Optional State Plan Services
• Dental Services
• Prescription drugs
• Clinic services
• Optometrist services
• Therapies (OT, PT, Speech)
• Personal Care
• Case Managment

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State Plan Services

• Combining required services specialty services
  under Rehabilitation option creation of
  integrated service delivery system
• Self-direction offers consumer control over
  entire health care package

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State Plan Services

• Some states have added peer support to Medicaid
  State Plan within the Rehabilitative Services
  benefit (GA, NY, SC)
• Georgia was first state to offer peer-delivered
  services
• Certified Peer Specialists support participants
  in their recovery teach participants how to
  manage symptoms use community resources

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State Plan Services (continued)

• Peer Specialists complete 8-day training must
  pass oral written exams (principles of
  recovery, self-help, peer support
  Medicaid-billable services)
• Specialists work for core service providers in
  free-standing Peer Support Centers
• Georgia trained provider management in recovery
  philosophy
• Cost about 6 million/year

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Section 1115 Demonstrations

• Allows self-direction of State Plan Services
  HCBS waiver services
• Allows States to develop experimental, pilot or
  demonstration programs
• Allows States great flexibility in program
  design, including self-directed services
  supports
• Consider partnering with other sources of funds

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Section 1115 Demonstrations

• Allows for services most resembling the recovery
  model
• Peer support services
• Micro-enterprise
• Supported employment/Supported education
• Consumer-run drop-in centers
• Housing supports (locating, maintaining)
• Transportation
• Personal care services
• Warm Line
• Supports brokering
• Consumer-run advocacy groups
• Traditional clinical services
• Individual Development Accounts

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Section 1115 Demonstrations

• Program must be budget neutral
• Federal Medicaid cost cant be more with
  demonstration than without demonstration
• BN accomplished, for example
• by substituting self-directed service delivery
  model for traditional day treatment
• savings may be realized by reduced use of
  inpatient hospital care or psycho-social
  rehabilitation

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Section 1115 Demonstrations
CMS is attempting to revise its IP template to
facilitate use of self-directed service delivery
model for persons with mental illness

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Section 1915 (c) Waivers

• Promotes HCBS as an alternative to care in
  institution
• States must show cost-neutrality (CN)
• Costs of the waiver services are less than/equal
  to Medicaid costs of services in an institution
• Institution includes only hospital, nursing
  facility or ICF/MR excludes Institutions for
  Mental Disease (IMD)
• Exception FFP is available for inpatient
  psychiatric services provided to those under age
  21 in IMDs
• Intermittent nature of care in IMDs lack of
  coverage for adults aged 22 65 means states
  have difficulty showing CN

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Section 1915 (c) Waivers

• Most common services
• Case management
• Homemaker
• Home Health Aide
• Personal Care Services
• Hospice
• Habilitation
• Respite
• Other (e.g., Adult Day Care)

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Section 1915 (c) Waivers

• Revised Waiver Application
• Recognizes that self-direction is a continuum of
  care
• Allows states the ability to incorporate
  self-direction into existing programs
• Incorporates self-direction into every aspect of
  program design
• Scope of Control
• Staff Control
• Budget Control

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Section 1915 (c) Waivers

• CMS HCBS Waiver Data
• More than 1 million people
• FFY 2003 Federal expenditures 18 billion
• FFY 2003 290 waivers/700,000 participants

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Section 1915 (c) Waivers

• Adults Colorado
• Successfully used authority by stating that, in
  absence of services, persons would be in a
  nursing facility

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Section 1915 (c) Waivers (continued)

• Children WI, VT, IN, KS, NY
• Vermont
• More than 20 years
• 110 children under age 22
• Services include emergency crisis intervention,
  respite, case management, individual, family and
  group therapy, psych consultation

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Section 1915 (c) Waivers (continued)

• Children WI, VT, IN, KS, NY
• Vermont
• Offers alternative to family placement
  Therapeutic Foster Home
• Average cost of psychiatric hospital services
  789/day/child
• Average cost of waiver services 128/day/child

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Section 1915 (c) Waivers

• Children (contd.)
• New York
• About 10 years
• Ceiling 1037 individuals 900 currently
• Children diagnosed with severe mental illness,
  aged 5 21

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Section 1915 (c) Waivers (continued)

• Services include respite, care coordination,
  family support services, crisis intervention,
  skill building services, intensive in-home
  supports and use of individualized care
  approach, sensitive to cultural, language needs
  of family
• Average cost for psych hospital services
  77,000/year/child
• Average cost for waiver services
  40,000/year/child

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Section 1915 (c) Waivers

• Kansas
• Since 1997
• 2,000 currently
• Children aged 4 22 diagnosed with chronic
  mental health conditions
• Services include respite, case management and
  rehabilitation delivered via wrap around system

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Section 1915 (c) Waivers (continued)

• Kansas
• rehabilitation delivered via wrap around system
• Uses several sources of funds SP Rehabilitation
  Option, EPSDT and waiver
• Average cost for hospital services
  15,000/year/child
• Average cost for waiver services 792/year/child
• www.srskansas.org
• www.kidstraining.org

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Section 1915 (c) Waivers

• Children (contd.)
• Wisconsin
• SED Waiver began January 2004
• 137 children up to age 22
• Uses several funding streams
• www.dhfs.state.wi.us

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1915 (b) Waivers

• Must address
• Program description
• Access
• Quality
• Cost Effectiveness
• Actual waiver service cost actual waiver
  administration cost is less than/equal to
  projected waiver cost
• Most are carve-out delivery systems for special
  care, e.g., Managed Behavioral Health Care Plan
  Disease Management

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1915 (b) Waivers

• Managed Care Waivers 1915 (b)(1)
• Mandates enrollment in managed care
• Uses MCO, PIHP, PAHP, PCCM funding organizations
• 60 of Medicaid beneficiaries are in managed
  care as of 2004
• 1915 (b)(3)
• Can use savings generated under waiver to pay for
  additional State Plan services which can be
  highly flexible, enabling states to create
  services supports such as consumer-run drop-in
  centers or peer support group programs

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1915 (b) Waivers

• Colorado Medicaid Mental Health Program
• Used savings to fund 4 drop-in centers in first 5
  years plan to fund 4 more
• Correlated waiver with use of recovery model of
  care
• Significant reductions in hospitalization no
  significant differences in most participant
  outcomes
• Significant outcome differences noted increases
  in daily activities decreases in homelessness
  under managed care

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1915 (b) Waivers

• Florida
• In addition to managed care to provide Medicaid
  services, the waiver includes a 9-county pilot in
  which FL contracts directly with specialty
  behavioral health organizations called the
  Prepaid Mental Health Plan
• Under both arrangements, CMH Centers are often
  part of MCOs provider networks
• Some Centers added peer specialists to array of
  services
• In one county, a Recovery Team composed entirely
  of consumers is providing counseling
  psycho-education as Medicaid services

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Section 1915 (b)/(c) Waivers

• Uses the 1915 (b) authority to limit freedom of
  choice the 1915 (c) authority to provide the
  hcbs permit expansion to a special eligibility
  group
• Must meet all federal requirements for both
  authorities
• Must submit separate applications for each waiver
  type
• Must demonstrate CN for 1915 (c ) CE for 1915
  (b)
• Must comply with separate reporting requirements
• Renewals at different points in time
• Permits states to develop innovative managed care
  program that integrates hcbs with traditional
  State Plan services

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Section 1915 (b)/(c) Waivers

• Michigan
• Medicaid Prepaid Specialty Mental Health
  Substance Abuse Services concurrent 1915
  (b)/(c) program approved in 1998
• Shifted financing through creation of Community
  Mental Health Services Programs
• Waiver promotes use of peer-delivered service
  models most regions have peer-run drop-in
  centers
• Requires committee of advocates, participants
  state staff to review managed care organization
  applications
• Requires advocates participants to be 2/3 of
  committee
• State legislation also requires implementation of
  person-centered planning for all specialty
  services

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Real Choice Systems Change Grants

• 2004
• 11 awards for Mental Health Systems
  Transformation Grants
• DE, MA, ME MN, NC, NH, OH, OK, OR, PA, VA
• Self-Direction Focus areas
• State-level advisory committee for self-direction
• Peer-operated services supports
• Training technical assistance for
  consumer-directed programs

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Real Choice Systems Change Grants

• 2003
• -12 awards for development of Independence Plus
  programs
• CT, CO, FL, GA, ID, LA, MA, ME, MI, MO, MT, OH
• www.cms.hhs.gov/newfreedom

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Real Choice Systems Change Grants

• 2003
• 6 awards for Community-Based Treatment
  Alternatives for Children (C-TAC) Grants
• IL, MA, MD, MO, MS, TX
• Psychiatric residential treatment facilities
  (PRTFs) have become primary providers of services
  to children with SED requiring an institutional
  level of care
• Grants are to assist states in developing a
  comprehensive, community-based mental health
  service delivery system for children with SED who
  would otherwise require care in a PRTF

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Real Choice Systems Change Grants

• 2001/2002
• Real Choice Systems Change Grants for developing
  enhancing needed infrastructure changes that
  foster enduring systems change
• MS OR used the 10 allowance for direct
  services to fund a self-directed pilot for
  persons with mental illness

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Real Choice Systems Change Grants

• 2005 Solicitation
• A more comprehensive coordinated approach to
  promoting systems change
• 3 funding opportunities including Systems
  Transformation Grants
• To begin or further current initiatives that
  target key elements of systems infrastructures
  such as self-direction
• 8 10 grant awards anticipated
• 1.5 3.5 million
• Application due 7/7/05
• Up to 10 of grant funds may be used to provide
  direct services
• 60-month grant period

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Other Grant Programs Medicaid Infrastructure
Grants

• An 11-year grant program
• Supports infrastructure development to expand
  supports services to workers with disabilities
• Grant award 500,000 per year or 10 of a
  states buy-in expenditures
• States must cover personal assistance services
• 42 states DC have been awarded funding to date

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Other Grant Programs Medicaid Buy-In

• The Medicaid Buy-in program provides health
  insurance to individuals with disabilities who
  are working
• Can charge premiums
• Two options
• BBA of 1997 somewhat more restrictive
• Limits income to 250 of poverty level for family
• Limits resources to SSI amount
• TWWIIA of 1999 somewhat more liberal
• State establishes own income and resources limits
• Limited to age range 16 64

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Roles for Consumers/Advocates

• Work to craft language to amend SSA that would
  permit benefits of a 1915 (c) waiver for children
  and adults
• Be at table re State Medicaid Reforms
• Assure active representation on statewide
  consumer advisory committees, but more
  importantly, transform committees into
  consumer-directed committees

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Roles for Consumers/Advocates

• Organize, strategize
• Be involved at local, county, state, provider
  levels

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Web Resources

• CMS Independence Plus
• www.cms.hhs.gov/independenceplus
• Promising Practices
• www.cms.hhs.gov/promisingpractices
• Systems Change Grants
• www.cms.hhs.gov/newfreedom

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Web Resources

• Robert Wood Johnson Foundation
• www.rwjf.org
• Mathematica Policy Research, Inc.
• www.mathematica-mpr.com
• Home and Community-Based Waiver Service Resource
  Network
• www.hcbs.org

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Web Resources

• CMS Waiver and Demonstrations
• www.cms.hhs.gov/medicaid/waivers
• Email CMS about Self-directed waiver or
  demonstration programs
• selfdirectionwaiver_at_cms.hhs.gov
• selfdirectiondemo_at_cms.hhs.gov