Self-Directed Support in a Changing Environment: Building Program - PowerPoint PPT Presentation

Self-Directed Support in a Changing Environment: Building Program Integrity Self Direction Conference May 8 , 201 7

Missouri Division of Developm ental Disabilities Kyla Mundwiller Missouri Division of DD Director of Self-Determination kyla.m undw iller@dm h.m o.gov

SDS in a Changing Environment- OIG Investigative Advisory on Medicaid Fraud and Patient Harm Involving Personal Care Services Issued by: Office of Inspector General (OIG), Department of Health and Hum an Services, Washington, DC To: Center for Medicaid and & CHIP, Center for Medicare & Medicaid Services October 3, 2016

SDS in a Changing Environment- OIG OIG Expects to Issue Report in 20 18 “ Data collected from the 50 State Medicaid Fraud Control Units (MFCUs) and OIG’s Office of Investigations which will include: indictments, convictions, and recoveries involving fraud and patient abuse or neglect. The data that w ill be presented in this brief “ are intended to illustrate the p rev a lence a nd m agnitud e of fra ud and p a tient abuse or neglect inv olv ing PCS .”

SDS in a Changing Environment- OIG Oversight & Effectiveness of Medicaid Waivers “ oversight of State waiver programs present challenges to ensure that p ay m ents m ad e und er the w aiv ers are consistent w ith rega rd s to efficiency , econom y , and quality of care and d o not infla te Fed eral costs.” “ w ill determ ine the extent to w hich selected States made use of Medicaid waivers and if costs associa ted w ith the w aiv ers are efficient, econom ic, and d o not infla te Fed era l costs,”

SDS in a Changing Environment- OIG 20 12 “Personal Care Services: Trends, Vulnerabilities, and Recom m endations for Im provem ent” • Services not provided in compliance with state requirements • Services not supported by documentation • Services during Medicaid-reimbursed institutional stays • PCS attendants who did not meet state qualification requirements • Findings related to billing practices include billing for services not rendered • Services provided to furnished to ineligible beneficiaries, Services provided by unauthorized caregivers. • Abuse and neglect of beneficiaries by PCS attendants, resulting in beneficiary harm

SDS in a Changing Environment- OIG OIG Recom m endations: Establish minimum Federal qualifications and screening standards for PCS workers, including background checks. Require States to enroll or register all PCS attendants and assign them unique numbers. Require that PCS claims identify the dates of service and the PCS attendant who provided the service. Consider whether additional controls are needed to ensure that PCS are allowed under program rules and are provided.

SDS in a Changing Environment- CMS Strengthen Program Integrity in Medicaid Personal Care Services Issued by: Center for Medicaid and & CHIP, Center for Medicare & Medicaid Services Dec 13, 2016

SDS in a Changing Environment- OIG-CMS CMS in Response to OIG Recom m endations: • Provider Qualifications and Basic Training • In many consumer-directed personal care programs, much of the training can also be provided directly by the beneficiary. • Screening of PCS Providers • FMS entity is considered the provider for purposes of screening and enrollment. Verification of Need for Services • Verification of Need for Services • Documentation of Claims • PCS providers, like providers of any other Medicaid services, must be able to document the provision of services for which they have submitted a claim for payment. • Prepayment Edits • Post-Payment Reviews

SDS in a Changing Environment- OIG -CMS CMS in Response to OIG findings: • The program integrity safeguards that m ake policy and operational sense in the case of a PCS agency w ith m any clients m ay not be suitable to an individual beneficiary directing his or her own PCS services. • States are again encouraged to collaborate w ith their stakeholders, including beneficiary advocates, to determ ine the m ethods of PCS delivery and the resulting program integrity protections that w ill prevent fraud and abuse while still m aintaining beneficiary autonomy in self-directed m odels. • CMS strongly encourages use of self-directed m odels w ith necessary supports using a person centered planning process.

SDS in a Changing Environment- GOP Health Policy Brief Modernizing and Strengthening Medicaid to Protect the Most Vulnerable The Medicaid program today is a critical lifeline for som e of our nation’s m ost vulnerable patients, as the program provides health care for children, pregnant m others, the elderly, the blind, and the disabled. Medicaid currently covers nearly 72 m illion Am ericans—m ore than Medicare — and up to 98 m illion m ay be covered at any one point in a given year. But today, the Medicaid safety net is under strain and not serving patients as w ell as it should. Ma ny sta te Med ica id p rogra m s suffer from significa nt w a ste, fra ud , a nd a buse, d ue to fa ilures in sta te a nd fed era l ov ersight. Issued by: GOP Health Policy Brief February 2017

Building Program Integrity If you have seen one self-directed support program you have seen one self-directed program . If you have seen one state structure for hom e and com m unity based supports you have seen one state's structure.

What is Self-Directed Supports ? Self-directed supports (SDS) is an option for service delivery for individuals, who live in their own private residence or that of their family member & who wish to exercise more choice, control and authority over their waiver supports. SDS is firmly grounded in the principles of self- determination.

Where did this all begin? 1993 Original Proposal to the Robert Wood Johnson Foundation. “If ind iv id ua ls a nd fa m ilies ha v e control of the resources, q ua lity w ill go up a nd cost w ill go d ow n.”

Self-Determination Principles Freedom : Individuals will live a meaningful life in the community and make choices about their lives. Authority: Individuals will have meaningful control over a set amount of dollars that can be used to build the supports that they need by purchasing only what is needed and paying for what is received. Support: Individuals will have support to organize resources in ways that are life enhancing and assist them in reaching their dreams and goals. Individuals have a circle of supports made up of family, friends and both paid and unpaid supports. Responsibility: Individuals assume responsibility for giving back to their community, for seeking employment, and for developing unique gifts and talents Confirm ation: Individuals are recognized for who they are and what they can contribute, having a leadership role in developing policies that affect their lives and helping others reach success.

Self-Directed Supports SDS is based on the prem ise that the individual and their representative know best about their needs and how to address those needs. The individual m ust be em powered to m ake decisions about the services they receive, including having choice and control over the type of supports they receive, who provides the supports and when and where the supports are delivered.

Shifting Pow er To From Individuals and families planning Professionals planning for for themselves individuals Reliance on the lifelong Reliance on paid commitment of individuals and professions who are only families to manage their own lives temporarily part of an individuals life Respect for the fact that individuals and families have a vested interest A view that only in acting responsible on their own professional can be behalf responsible Support Coordination & Support Brokerage as a means for Support Coordination as a individuals and families to create means to let people into services in response to their needs existing services and dreams

A Brief National History 1993 Original Proposal to the Robert Wood Johnson Foundation (RWJF) 1995 Statewide in New Hampshire 1996 RWJF go National 19 states 1998 10 more states 2002 CMS announces Independence Plus imitative 2004-07 CMS revised waiver application to allow SDS

2013

A Brief Missouri History 1998 Missouri’s State Planning Council(MPC) “Show Me Change: Building A Participant-Driven System For Missourians With Developmental Disabilities .” The report concluded: “ Resources for supports in Missouri m ust be allocated and expended from a person-centered rather than a provider centered perspective.” “ Individuals m ust be in control of their allocated resources for services and supports and how they are delivered.” 2003 “ DMH Practice Guidelines for Consum er Directed Supports and Services” 2003 Independence Plus Grant

A Brief Missouri History Fiscal Intermediary Program Demographics for FY2003 81 Families participated in the FI program Only 15 Individuals were their own employer. Marvin Wilson contract for payroll. 1999-2007 2001 Columbia EDP did payroll. Timesheets were entered into CIMOR by Regional Office (RO) staff. Service Coordinators and sometimes RO staff were responsible for employer & employee enrollment packets.