# Presentation: 815797

## SAMHSA & CMS Free AudioNet Training:	Self-Direction in Mental HealthThursday, November 6, 20083:00 p.m.- 4:30 p.m. EST

- Sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA)/Center for Mental Health Services (CMHS) & the Centers for Medicare and Medicaid Services (CMS)

## WELCOME

- Paolo del Vecchio, MSW
*	**Associate Director for Consumer Affairs*
*	**SAMHSA/CMHS*
*	*

## Overview of Training

- Robert Glover, Ph.D.
- 	*Director,* *National Association of State Mental Health Program Directors*
_**AGENDA**_
- Summary of Self-Direction Requirements in Medicaid
- Florida’s Perspective from State MH Commissioner
- Self-Directed Care Participant Perspective
- Home and Community Based Services - Section 1915(c) Waiver Programs & Section 1915(i) State Plan Options
- Section 1915(j) Self-Directed Personal Assistance State Plan Option
- Questions and Answers, Wrap-Up

## Speaker Biographies

**Katharine V. Lyon, Ph.D**. is a clinical psychologist with a specialty in substance abuse treatment and research.  She is the Mental Health Director for the State of Florida within the Department of Children and Families.  The position requires the oversight of the community based system of care along with the forensic and civil mental health facilities. She is experienced in system development within the field of behavioral healthcare.
**Diann Mayo** is a former self-directed care participant in Florida. Currently, she is the chair of the Florida Self-Directed Care Advisory Board and is a certified peer support specialist.

## Speaker Biographies

**Marguerite Schervish** has been employed as a Health Insurance Specialist at CMS for 6 years.  Her areas of concentration include self-direction, State Plan Amendments, section 1115 demonstration programs and the Program of All-inclusive Care for the Elderly (PACE).
**Kathryn Poisal** is a licensed social worker and works as a health insurance specialist at CMS.   For the past ten years, she has served as a Federal policy analyst for Medicaid 1915(c) home and community based services waivers.  She is also the lead analyst for the 1915(i) Medicaid State plan home and community based services benefit.

## Part 1: Summary of Self-Direction and Medicaid

- Marguerite SchervishCenters for Medicare & Medicaid Services_[Marguerite.Schervish@cms.hhs.gov](mailto:Marguerite.Schervish@cms.hhs.gov)_

## Summary of Self-Direction Requirements in Medicaid

- Assessment – needs, wants, preferences
- Person-centered & directed planning/plan
- Individual budget
- Support system – information, counseling, training & assistance; includes supports brokers/consultants & financial management services
- Quality management system

## CMS Self-Direction Requirements: Assessment

- Evaluation of the individual’s needs, strengths, preferences for services
- Obtains holistic information about individual & environment
- Supports development of person-centered plan and budget

## CMS Self-Direction Requirements: Person-Centered & Directed Planning

- Service plan & budget are developed using a person-centered & directed process
- Can use supports broker/consultant/ to facilitate the planning process and development of the person-centered plan
- Can use any appropriate planning model, e.g., WRAP (Wellness Recovery Action Planning), PATH (Planning Alternative Tomorrows with Hope), Essential Lifestyle Planning, MAPS (Making Action Plans), Personal Futures Planning and Recovery Planning.)
- *Participants direct the process including who is invited to participate in the planning meetings

## CMS Self-Direction Requirements: Person-Centered & Directed Planning

- Participants’ preferences, choices & abilities & strategies to address those preferences, choices & abilities must be identified in the person-centered plan
- We recognize the importance of setting goals for recovery
- Among other things, the plan must include an individualized back-up plan for contingencies that pose a risk of harm to participants, such as what to do in the even of a crisis; also consider a psychiatric advance directive
- The risks that participants are willing & able to assume (”risk management plan”)

## CMS Self-Direction Requirements: Individual Budget

- The amount of funds under the control & direction of a participant; Medicaid funds must have separate audit trail
- Developed using a person-centered & directed process
- Based on the assessment & the person-centered plan
- Individually tailored in accordance with the participant's needs & personal preferences as established in the person-centered plan

## CMS Self-Direction Requirements: Supports for Self-Direction

- Generally: information, training, counseling or assistance for effective self-direction of services & supports
- Support Brokers/Consultants:
- Facilitate participants’ choices, development of person-centered plans & budgets, & effective management of participants’ services & budgets in a manner that comports with participants’ preferences
- Supports brokers/consultants take their direction from participants about what information, training, counseling & assistance participants may want or need
**Note: They have different roles and responsibilities than “case managers”*

## CMS Self-Direction Requirements: Supports for Self-Direction

- Financial Management Services (FMS):
- Activities include payroll, tax reporting, payment of taxes, monitoring & accounting for individual budget expenditures
- 	_Section 1915(j) only_: If applicable, individuals that elect the cash option can perform some or all of the FMS activities themselves, including the tax functions
- States may employ an FMS entity or provide the FMS themselves

## CMS Self-Direction Requirements: Quality

- States must assure that necessary safeguards have been taken to protect the health & welfare of participants & to assure financial accountability
- States must provide a quality assurance & improvement plan/strategy with methods for on-going measurement of system/program performance measures and quality of care/outcome measures
- This plan must include mechanisms for discovery, remediation, and systems improvement

## Part 2: Florida’s Perspective

- Katharine V. Lyon, Ph.D.
- 	Director, Mental Health Program Office
- 	Florida Department of Children and Families
- 	PH: 850-413-9610

## Part 3:Florida’s Perspective

- Diann Mayo
- 	Chair, Florida Self-Directed Care Advisory Board
- 	Former self-directed care participant
- 	Email: _[mdia155@yahoo.com](mailto:mdia155@yahoo.com)_

## Part 4:Medicaid Home and Community Based Services (HCBS): 1915(c) Waivers & 1915(i) State Plan Services

- Kathy Poisal
- 	Disabled and Elderly Health Programs Group, CMSO, CMS
- 	_[Kathryn.poisal@cms.hhs.gov](mailto:Kathryn.poisal@cms.hhs.gov)_

## 1915(c) HCBS Waivers 

- A program of services under Section 1915(c) of the Social Security Act that permits States to waive certain Medicaid requirements
- Permits States to provide HCBS to people eligible for Medicaid, who would otherwise require services in an institution (nursing home, ICF/MR, or hospital)** **

## 1915(c) HCBS Waivers

- Waiver services complement and/or supplement other available services (Medicaid State plan, other Federal, state & local public programs, supports from families & communities)
- Serves diverse target groups – including persons with mental illness
- Can include participant-direction of services, at State option

## 1915(c) HCBS Waivers

- States have flexibility in designing HCBS waivers:
- choice of target group(s)
- option to only provide services to particular areas within state (waive statewideness)
- choice of waiver services
- opportunities to allow for self-direction
- determine provider qualifications
- quality management strategy

## 1915(i) State Plan HCBS Benefit

- New section 1915(i) established by DRA of 2005, effective January 1, 2007
- State option to amend the state plan to offer HCBS as a State plan benefit
- Unique State plan benefit with similarities to 1915(c) HCBS waivers
- Breaks the “eligibility link” between HCBS & institutional care

## Who May Receive 1915(i) State plan HCBS?

- Must be eligible for medical assistance under the State plan
- Must have income that does not exceed 150% of FPL
- States must provide needs-based criteria to establish who can receive the benefit

## State Plan HCBS1915(i) permits the statutory 1915(c) services:

- Case management
- Homemaker
- Home Health Aide
- Personal Care
- Adult Day Health
- Habilitation

- Respite Care For Chronic Mental Illness
- Day treatment or Partial Hosp.
- Psychosocial Rehab
- Clinic Services

## State Plan HCBS

- 	1915(i) permits the statutory 1915(c) services, but NOT the 1915(c) “Other” flexibility to design unique HCBS waiver services.

## Mental Health Services

- 1915(i) services for persons with chronic mental illness:
- Day Treatment or Partial Hospitalization
- Psychosocial Rehabilitation
- Clinic Services
-  No institutional level of care requirement; no cost neutrality requirement

## State Options

- States can limit number of participants who may receive benefit
- States can limit services to specified State areas (option to not apply statewideness)
- Self-Direction

## HCBS Waivers & State Plan HCBS with Self-Direction

- Permits beneficiaries to exercise decision-making authority over some/all services and accept the responsibility for taking a direct role in managing them
- May allow for recruiting/hiring/firing staff
- Includes Employer Authority and/or  Budget Authority
- Includes individualized supports – Information/Assistance and Financial Management Services

## HCBS Waivers & State Plan HCBS with Self-Direction

- Required Elements of Self-Direction Option:
- Assessment of needs, capabilities, & preferences;
- Individualized service plan directed by the individual or the individual’s authorized representative;
- Description of the self-directed services & self-directed opportunities (employer &/or budget authority);
- Description of self-directed individual budgeting method & safeguards (may include budget, varies by State);
- Assistance in Support of Self-Direction (Supports Brokerage) & financial management services;
- Transition Safeguards

## 1915(c) HCBS Waivers -- Resources

- Revised waiver application for States to apply for a 1915(c) HCBS waiver available in both Word© and web-based formats
- The application has a robust set of accompanying instructions.
- Both documents are available at:
- https://www.hcbswaivers.net

## 1915(i) State plan HCBS:

- For more information...
- Regulation published as NPRM April 4, 2008  with comment period ending June 3, 2008.
- 	Complete proposed rule (CMS-2249-P) at
- 	_[http://www.cms.hhs.gov/MedicaidGenInfo/08_Medicaidregulations.asp](http://www.cms.hhs.gov/MedicaidGenInfo/08_Medicaidregulations.asp)_
- State Medicaid Directors Letter released
- 	April 4, 2008
- Draft application available to State Medicaid agencies through the CMS regional offices

## Technical Assistance

- CMS has contracted with Acumen, LLC and their accomplished team of consultants to provide technical assistance to State Medicaid agencies at all stages of program  development and implementation.
- Acumen, LLC can provides assistance in determining which authority will best meet State needs, and assistance in understanding CMS requirements and designing programs accordingly.
**Technical Assistance will cover the areas of:****	****	**
-  Home and Community Based Services [1915(i) and 1915(j)]
- Self-Directed Personal Assistance Services State Plan Option [1915(j)]
-  Self-Directed Services
- Person-Centered Planning
- Other areas as needed by States
- This technical assistance is available at no cost to State Medicaid agencies.
- To request technical assistance from Acumen, LLC, contact your CMS Regional Office, or Acumen at HCBS-support@acumenllc.com.

**www.HCBSSelfDirection.org**

## Part 5: Section 1915(j) of the Social Security Act: Self-Directed Personal Assistance Services State Plan Option

- Marguerite SchervishCenters for Medicare & Medicaid Services_[Marguerite.Schervish@cms.hhs.gov](mailto:Marguerite.Schervish@cms.hhs.gov)_

## Section 1915(j) Features

- Effective 1/1/07 (Enacted as section 6087 of the Deficit Reduction Act of 2005)
- States may elect to provide self-directed personal assistance services (PAS) in the State Plan so demonstrations and waivers would not be necessary

## Section 1915(j) Features

- What are self-directed PAS?
- Personal care and related services under the Medicaid State plan, and/or
- Home and community-based services under section 1915(c) waiver
*...**that the State *_*already*_* has in place (Section 1915(j) offers the self-directed service delivery model, *_*not*_* new services)*
- If selected by the State, PAS  may also include “permissible purchases”

## Section 1915(j) Features

- Individuals have “employer” authority - can hire, fire, supervise and manage workers capable of providing the assigned tasks,
- AND
- Individuals have “budget” authority - can purchase personal assistance and related services from their budget allocation

## Section 1915(j) Features

- Participation is voluntary
- Participants set their own provider qualifications & train their providers of PAS
- Participants determine amount paid for a service, support or item

## Section 1915(j) Features

- If a State elects the section 1915(j) option:
- The State could limit the option to certain areas of the State or offer it statewide
- The State could target the population using section 1915(c) waiver services
- The State could limit the number of individuals who will self-direct their PAS

## Section 1915(j) Features

- If the State Medicaid agency also elects the following, participants may:
- Hire legally liable relatives (e.g., parents, spouses)
- Manage a cash disbursement
- Purchase goods, supports, services or supplies that increase their independence or substitute for human assistance (to the extent expenditures would otherwise be made for the human assistance) (“permissible purchases”)
- Permissible purchases must relate to a need or goal identified in the person-centered plan
- Use a discretionary amount of their budgets to purchase items not otherwise delineated in the budget or reserved for permissible purchases

## Section 1915(j) Features

- Additional Requirements:
- Option to self-direct PAS under section 1915(j) is not available to an individual who resides in a home or property that is owned, operated or controlled by a PAS provider who is not related to the individual by blood or marriage
- Annual Report – include numbers self-directing & total expenditures
- Triennial Evaluation – of the overall impact of the self-directed PAS option on health & welfare of participating individuals compared to non-participants

## Hypothetical

- Assume a State offers the personal care services (PCS) benefit in its State plan & defines PCS very broadly to include activities of daily living (ADLs), instrumental activities of daily living (IADLs), cueing & supervision.
- Assume also that the State offers the self-directed PAS State plan option for persons who need and are eligible for the PCS benefit and allows persons the option to purchase items that increase independence or substitute for human assistance.
- An individual with a mental illness is assessed to be physically capable of performing ADLs, but is easily distracted and experiences other barriers to taking care of his/her IADLs (personal hygiene, meal preparation, transportation, grocery shopping, using the telephone, medication management &  money management) .  The individual’s recovery goals in the person-centered plan include learning to purchase more nutritious groceries, improving his/her personal appearance and learning to cook.
- Under the self-directed PAS State plan option, this person could hire someone to help him with his/her IADLs of personal hygiene, grocery shopping and cooking.  This person could also accumulate funds to purchase some cookbooks as this is related to the goal of learning to cook.

## Approved State Plan Amendments (SPAs)

- Approved SPAs:
- Alabama was the first State to submit their SPA and obtained approval on 5/24/07
- Oregon’s SPA was approved on 1/10/08
- Arkansas’ SPA was approved on 3/27/08
- Florida’s SPA was approved on 3/28/08
- New Jersey’s SPA was approved on 7/23/08

## Approved State Plan Amendments

- Of the 5 approved SPAs:
- FL, AR, NJ - Offer self-direction of PCS State plan benefit
- AL, OR, FL, AR -  Offer self-direction of section 1915(c) waiver services
- OR, FL, AR, NJ - Offer opportunity statewide
- AL - Offers opportunity less than statewide
- Al, OR, AR, NJ - Offer the cash option

## Approved State Plan Amendments

- Of the 5 approved SPAs: (cont’d.)
- NJ, AL, FL, OR - Offer the option to hire legally liable relatives
- AL, FL, AR - Limit the number of individuals
- Populations included (in the aggregate): _elderly_ (AL, FL, AR, OR); _adults with physical disabilities_ (AL, FL, AR, OR); _persons with traumatic brain/spinal cord injuries_ (FL); _persons with developmental disabilities_ (AL, FL)

## Resources

- SMD Letter and Preprint:
- http://www.cms.hhs.gov/SMDL/SMD/ [Search “Personal Assistance Services” or SMD #07-013]
- Proposed Rule on Section 1915(j) Self-Directed PAS State Plan Option Published in Federal Register on 1/18/08
- http://a257.g.akamaitech.net/7/257/2422/01jan20081800/edocket.access.gpo.gov/2008/pdf/08-115.pdf
- Final Rule on Section 1915(j) Self-Directed PAS State Plan Option Published in Federal Register on 10/3/08
- http://federalregister.gov/OFRUpload/OFRData/2008-23102_PI.pdf
- http://frwebgate4.access.gpo.gov/cgi-bin/PDFgate.cgi?WAISdocID=322294382120+13+1+0&WAISaction=retrieve
- For further information:
- Carrie Smith, 410-786-4485, Carrie.Smith@cms.hhs.gov or Marguerite Schervish, 410-786-7200, Marguerite.Schervish@cms.hhs.gov

## Resources

- HCBS Clearinghouse for the Community Living Exchange Collaborative
- 	  http://hcbs.org/`
- Self-Direction in Mental Health Broadcast Series
- http://www.connectlive.com/events/samhsa/archived.html
- Free to Choose: Transforming Behavioral Health Care to Self-Direction
- http://mentalhealth.samhsa.gov/publications/allpubs/SMA05-3982/default.asp
- Florida Self-Directed Care
- 		http://flsdc.org

## Contact Information

- Centers for Medicare & Medicaid Services (CMS):
- Carrie Smith, 410-786-4485
- 		_[Carrie.Smith@cms.hhs.gov](mailto:Carrie.Smith@cms.hhs.gov)_
- Marguerite Schervish, 410-786-7200
- 		Marguerite.Schervish@cms.hhs.gov
- Kathy Poisal
- Kathryn.Poisal@cms.hhs.gov

## Contact Information

- Substance Abuse and Mental Health Services Administration (SAMHSA)/Center for Mental Health Services (CMHS):
- Paolo del Vecchio, 240-276-1946
- 		paolo.delvecchio@samhsa.hhs.gov
- Carole Schauer, 240-276-1948
- 		carole.schauer@samhsa.hhs.gov
- Stacey Lesko, 240-276-1390
- stacey.lesko@samhsa.hhs.gov

## Contact Information

- Florida Presenters:
- Katharine V. Lyon, Ph.D.
- 	Director, Mental Health Program Office
- 	Florida Department of Children and Families
- 	PH: 850-413-9610
- Diann Mayo
- 	Peer Support Specialist and former SDC participant
- 	Email: Mdia155@yahoo.com

## Part 6:

_**Questions and Answers**_