USING MEDICAID TO SUPPORT SELFDETERMINATION

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USING MEDICAID TO SUPPORT SELF-DETERMINATION

• 7TH ANNUAL MICHIGAN SELF-DETERMINATION CONFERENCE
• June 15, 2004

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Agenda

• Review Medicaid Basics
• Explain how new (b)(3) services are to be used
• Define Medical Necessity Criteria
• Relate considerations about using Medicaid
  services in self-determination arrangements

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MEDICAID BASICS

• In Michigan covered mental health Medicaid
  Services are
• Medicaid State Plan Services
• 1915(b)(3) or additional supports and services
• 1915(c) Waiver or Habilitation Supports Waiver
• And are known as Mental Health Specialty
  Services and Supports that are the
  responsibility of the 18 Pre-paid Inpatient
  Health Plans (PIHPs)

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MEDICAID BASICS

• MEDICAID COVERED SERVICES are
• Entitlements and therefore subject to Fair
  Hearing when a beneficiary disputes an action
  that denies, reduces, suspends or terminates the
  service
• Described in Chapter III of the Medicaid Policy
  Manual

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MEDICAID BASICS

• State plan services required services others
  selected by states from a menu of options
• In Michigan a mix of primary health care and
  mental health care services
• 27 Inpatient, medical, clinic, and other
  rehabilitative services

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MEDICAID MH STATE PLAN SERVICES

• ACT
• Assessments
• Behavior management review
• Child therapy
• Clubhouse
• Crisis interventions
• Crisis residential
• MH Therapies
• Health services
• Home-based services

• Intensive crisis stab.
• ICF/MR
• Med admin review
• Nursing facility mon.
• OT, PT and Speech
• Personal care in spec res
• Substance abuse
• Targeted case management
• Transportation
• Treatment Planning

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MEDICAID BASICS

• 1915(b)(3) or additional services are those a
  state can offer out of its Medicaid savings
• 1915(b)(3) services are defined by the state and
  approved by Centers for Medicare and Medicaid
  Services (CMS)
• In Michigan there are 13 (b)(3) services
  available to persons with MI or DD

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1915(b)(3) SUPPORTS AND SERVICES

• Assistive Technology
• Community Living Supports
• Enhanced Pharmacy
• Environmental Modifications
• Extended Observation Beds
• Family Support Training

• Housing Assistance
• Peer-delivered Support
• Prevention-Direct models
• Respite Care
• Skill-building Assistance
• Support Serv. Coord
• Supported Employment
• Wraparound for Children Adolescents

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MEDICAID BASICS

• Waivers
• Waive certain requirements of Medicaid regulation
  
• 1915(c) Waiver or home and community-based
  waiver
• restricts eligibility to certain target
  populations
• enables people who would otherwise be
  institutionalized, to choose community
  alternatives

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MICHIGAN MEDICAID

• In Michigan there are three 1915(c) or Home and
  Community Based Waivers
• MI Choice (Elderly and Disabled)
• Childrens Waiver (Children with Developmental
  Disabilities)
• Habilitation Supports Waiver (Persons with
  Developmental Disabilities)
• Only this one is part of the Specialty Services
  and Supports managed care program

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1915(c) or Habilitation Supports Waiver Services

• Chore
• Community Living Supports
• Enhanced Dental
• Enhanced Medical Equipment Supplies
• Enhanced Pharmacy
• Environmental mods

• Family Training
• Non-voc hab
• PERS
• Prevoc services
• Private duty nursing
• Respite
• Supports Coordination
• Supported employ.

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UNDERLYING ASSUMPTIONS

• Medicaid pays for services that are medically
  necessary
• Medicaid is payer of last resort
• Specialty Services and Supports can complement
  but not supplant state plan services

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UNDERLYING ASSUMPTIONS

• Medicaid Services that need particular attention
• State Plan vs. Specialty Services
• Home help CLS
• Case management Supports Coordination
• Transportation Transportation

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UNDERLYING ASSUMPTIONS

• A Medicaid card entitles a person to services
  that are medically necessary
• The individual plan of service resulting from
  person-centered planning specifies
• Amount
• Duration
• Scope
• When service begins and ends

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MEDICAL NECESSITY CRITERIA

• Services that are medically necessary are
• Necessary to screen assess the presence of MI,
  DD or SA
• Required to identify evaluate MI, DD, or SA
• Intended to treat, ameliorate, diminish or
  stabilize the symptoms of MI, DD, or SA
• Expected to arrest or delay progression of
• Designed to assist with attaining or maintaining
  sufficient function to achieve goals of

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MEDICAL NECESSITY CRITERIA

• Continued,
• Community inclusion and participation
• Independence
• Recovery
• Productivity

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MEDICAL NECESSITY CRITERIA

• Determination of a medically necessary support,
  service or treatment must be
• Based on personal information
• Based on clinical information
• Based on Person-centered planning
• Made by trained professionals
• Made within standards of timeliness
• Sufficient in amount, scope and duration to
  achieve its purpose

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INTENTS PURPOSES

• Design of new Medicaid mental health services
  since 1995 was to
• Provide flexibility
• Support consumer choice
• Promote independence, inclusion, freedom
• Build upon existing strengths (of the person, his
  network, his community)

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INTENTS PURPOSES

• Design intended to move from
• Day program slots to growing learning
  activities at home and in the community
• Work activity programs to real jobs
• Specialized residential beds to supported
  independent living, and supported shared
  housing
• Traditional medical equipment to supportive
  devices enabling full capacity

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INTENTS PURPOSES

• Design, continued
• Flexible options in Hab Supports Waiver
• Supports Coordination
• Community Living Supports
• 1998, then 2003 requirement that PIHPs offer
  (b)(3) supports and services for their Medicaid
  beneficiaries
• Flexibility in choice of providers/workers
• Options for self-directed supports

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USING MEDICAID FUNDS

• STARTS WITH
• Good person-centered planning
• What is the desired future?
• What will it take to get there?
• What resources are available in the network
  community?
• What service(s) are needed from the Medicaid
  program?

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USING MEDICAID FUNDS

• CONTINUES WITH
• Is the support or service identified medically
  necessary?
• What is the amount, scope and duration of the
  Medicaid support or service that will meet the
  need(s)?
• AND

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USING MEDICAID FUNDS

• If using (b)(3) supports and services
• Is there a goal of community inclusion and
  participation, independence or productivity?
• Is the service expected to achieve the goal(s)?
• Will it be provided in least restrictive setting?
• Does it supplant or complement state plan
  service(s)?

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USING MEDICAID FUNDS

• CONTINUES WITH DECISIONS ABOUT
• What mechanisms will be used for selecting,
  hiring, paying and firing the workers who provide
  support?
• Note
• Self-determination is not a covered Medicaid
  service, however
• Medicaid funds can be used for fiscal
  intermediary services but they are not
  separately billable or reportable

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USING MEDICAID FUNDS

• CULMINATES IN A
• Plan of Service that
• Explicitly identifies the amount, duration
  scope of services that were authorized to be
  provided by the PIHP staff or its provider
  network Identifies the amount, duration scope
  of other services that have been committed by
  FIA, Rehab Services, etc
• Identifies the responsibilities of key players
  individual, family, supports coordinator (e.g.,
  who is going to direct what and when)

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USING MEDICAID FUNDS

• In a self-determination arrangement, the plan
  will also contain
• The budget
• The roles and responsibilities of all parties
• PIHP or its subcontractor
• Fiscal intermediary
• Consumer
• Parameters for making changes in amount, scope
  and duration of services

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USING MEDICAID FUNDS

• In self-determination arrangements
  considerations
• Activities of support or service must meet
  definitions in Chapter III
• Qualifications of providers, no matter how
  selected, must meet those in Chapter III
• There must be a plan of service
• Services provided must be documented as
  delivered, and then they must be reported