Tip:
Highlight text to annotate it
X
>> Okay. Wonderful.
Wonderful.
Good afternoon, everyone.
My name is Serena Lowe and I'm a senior policy advisor to the Office
of Disability Employment Policy within the U.S. Department of Labor.
And it's my wonderful privilege to welcome you all to today's webinar,
the first in a two-part series that we are hosting
in collaboration with our colleagues at CMS.
And we're delighted today to have our assistant secretary, Kathy Martinez,
here to provide a few introductory remarks.
So, I'll turn it over to Assistant Secretary Martinez.
>> Thank you, Serena, and welcome everyone to today's webinar.
We at ODEP are delighted to host this national dialogue
which will highlight some great policy advancement from our partners at the Centers
for Medicare and Medicaid services.
We call them CMS.
This is the first in a two-part webinar series that we're hosting to help state policy makers
and disability stakeholders learn about recent CMS policy development that can be used
to inform -- and support state's employment first system change efforts.
There are many parallels between health and employment for folks with disability.
State Medicaid programs played a super critical role in supporting with people with disabilities
and supporting folks with disabilities to live,
work and participate meaningfully in typical community settings.
And that's why we've been working hard with our partners at CMS to find ways to collaborate
on sharing information and leveraging technical resources.
2014 I would say is a fantastic and exciting time
as the Affordable Care Act implementation comes into full force and ODEP is strongly committed
to supporting CMS as it works toward implementation of this great act.
We are pleased by the tremendous efforts of our colleagues at CMS
to issue really strong policy guidance that reinforces the importance
of providing services funded by state Medicaid in the most integrated settings possible.
And hopefully, by the end of today's discussion, you'll have a really great sense
of the various ways that states can use, the myriad of state Medicaid plans
and waiver options to promote integrated employment
and community engagements for folks with disabilities.
Now, I'm going to turn the program back over to Serena, and thank you all for attending
and I know you're going to learn a lot.
>> Thank you so much, Assistant Secretary Martinez.
We are -- we're just really so blessed to have as a wonderful leader
who really gets the importance of cross-systems collaboration and makes this all "walk our talk"
in terms of, really a coordinating efforts and reaching out to our partners
across other federal agencies to do what we can to promote policies at the federal level
and also at the state and local level that improve employment opportunities
and socioeconomic advancement of citizens of disability.
So, thank you so much, Assistant Secretary Martinez for getting us started.
It's now my pleasure as the webinar facilitator to introduce our two colleagues
who will be our key presenters today from the centers for Medicare and Medicaid services.
Colleen Gauruder has been employed with the Division of Long-Term Support Services
and Supports at CMS since January of 2011,
and serves as the division's subject matter expert on employment.
And also, on the division's employment team.
Prior to her work at CMS, she was employed with the state
of Maryland's developmental disabilities administration
where for many years she's held the position of statewide coordinator
for transition and employment services.
During her tenure at the state of Maryland, Colleen implemented several new programs
and initiatives including employment first initiatives, self-employment initiatives,
and fiscal incentive programs for employment of individuals
with developmental and intellectual disabilities.
She's also prior to her state employment, she has worked with an array
of community service providers and even formally as a director of Supportive Living
and Senior and Employment Coordinator.
So, she's really walked in many of the shoes of the professionals who are on the call today
at a state level and also at a provider level.
So, I think she's going to have some --
a great perspective in how you can utilize various state waiver and plant --
Medicaid plan options to really further your own systems change efforts on the ground
to increase employment opportunities for individual's significant disabilities.
Our second presenter from CMS is Jeff Clopein, and Jeff was --
has been employed with CMS in the division
of community assistance transformation since June of 2010.
He is the CMS project officer for the Medicaid Infrastructure Grant program
and the Money Follows the Person grant program.
And he works with a team of folks at CMS who overseas
and monitors the NFP program and several states for the MIGs.
He's also a member of the CMS Employment Workforce team, as well.
Prior to his tenure at CMS, he was with one of our other federal colleagues,
U.S. Department of Education's Rehabilitation Services Administration for four years.
So, he also brings a really strong entrenched policy expertise to the table,
and how these various federal policies and assistance can interact and engage
to further employment and economic advancement of citizens with disabilities.
So, now, we just -- I just want to echo Assistant Secretary Martinez's point,
and really show our gratitude to our colleagues at CMS who have been working tirelessly
on a number of policy, development initiatives and also to provide support to states
who are really trying to shift the focus of their Medicaid funds for long-term supports
and services for individuals with disabilities to make sure that they are
in the most integrated setting and that folks really have an opportunity to succeed
and achieve their American dreams within typical community settings like the rest of us.
So we just -- we're very proud partners of CMS and of both Colleen and Jeff,
specifically, and appreciate their time today.
And with that, I'm happy to turn it over to our colleagues.
>> [Inaudible].
It's a pleasure to be here with you today and thank you so much
to Assistant Secretary Martinez for her opening remarks
and to Serena for arranging this webinar.
We're very excited to share the information that we have with you today and we'll allow plenty
of time for questions and answers, any questions that we're not able to answer today,
we will get back with you on and we'll make those arrangements through Serena.
I wanted to just take a minute to remind folks about the purpose of this particular webinar,
which is to share information with you about the various Medicaid authorities that exist
to support employment for people with disabilities and the elderly.
And also to provide information on various different grant programs that we have
through CMS that also further the goals
of employment outcomes for people with disabilities.
The purpose of this webinar is not to talk about the home and community-based settings rules,
which I'm sure you're all very eager and anxious to hear about.
That will be next week's call with my supervisor, Ralph Lollar.
So, stay tuned for that information.
Jeff and I are not prepared to talk about that particular subject today,
and that information will be coming to you next week.
So, I just wanted to clarify what the purpose of today's webinar is.
So, there are various different Medicaid authorities that support employment,
including 1915 c home and community-based waiver services, which is a service
that probably the majority of you on the phone are the most familiar with.
We have approximately 340 1915 c waivers across the country.
I would say a little less than 100% of them includes, some type of support
in employment settings, either day hab, prevocational supported employment,
career planning, but the majority of waivers that we support
through our work do include some type of -- employment type of services.
We're also going to touch base on the 1915 i state plan options for home
and community-based services -- the 1915 j, the 1915 k,
and we could go on through the alphabet right all the way to Z, but we're not going to today.
That's for another day.
And, we're going to talk also a little bit about 1115 demonstrations
and how the 1115 demonstration work ties into employment services, as well.
So, I'm going to go ahead and advance the slides now.
The 1915 c home and community-based waiver services were established in 1981
and they provide home and community-based services to individuals
who require an institutional level of care.
So, either nursing facility, ICF IDD, or a hospital level of care.
The 1915 c allows the option to offer various services including habilitation,
which may also include day hab, prevocational, individual supported employment groups,
supported employment and career planning.
On September 11th -- I'm sorry, September 16, 1911 -- 2011 --
CMS put out an informational bulletin to all of its stakeholders regarding employment supports
and services and I wanted to go over some of the highlights of the information bulletin
because that informational bulletin is our latest policy on employment support.
So, if you don't have a copy of that 911 bulletin --
informational bulletin, make sure you get your hands on a copy of it,
and you could get that through going to medicaid.gov and doing a search
of informational bulletin 91611 and that is really the [inaudible] for our discussion today
and sort of the tipoff point for our discussion today.
So, the informational bulletin, which provides technical guidance to states,
underscores CMS' commitment to the importance of work for waiver participants.
We believe that all participants with disabilities regardless of the severity
of the disability can work, and should be supplied with the supports that they need
in order to achieve employment outcomes.
It supports state efforts to increase employment opportunities
as meaningful community integration for waiver participants.
We recognize that there are -- let's see, how many of you are there on the phone right now?
I would say there are probably close to 300 people on the phone right now,
314 participants so far on the phone now of you probably representing around 30 or so states.
There's also another technical assistance opportunity that's available to states
through the National Association of State Directors of Development Disabilities Services,
which also offers similar types of technical assistance to about 27 other states.
Also, I think just about every state in the nation is covered with some type of assistance
for furthering your employment's first goals.
So, we're hopeful that this informational bulletin actually supports your efforts
in furthering employment outcomes for people.
It also provides further clarification of CMS guidance regarding several
of the core definitions and adds several new core service definitions.
So, we have in our technical guides currently several core service definitions
such as day habilitation prevocational and supported employment,
and what we did is elaborated on those definitions, adding either --
either adding some clarification to some of them, or adding additional service definitions
so that states have a little bit more flexibility in the way
that they're providing services to people.
The informational bulletin provides a strong preamble that highlights the importance
of competitive work and CMS' goal to promote more integrated employment options and waivers.
So, in state's work with analysts at CMS, when you're submitting an amendment or a renewal,
or an 1115, or a 1915 b or a 1915 i, we will have the conversation with you about employment.
Employment is high on our radar screen.
It's a high priority for us and we want to make sure that this informational bulletin
that I'm talking about is enforced the way it should be.
It's intended to provide you with guidance
on how you could create your core service definition.
You could either use CMS' core service definition, or you could create your own as long
as you have the tenets of CMS' core service definition within your own service definitions.
So, we allow you a bit of flexibility and how you actually word your core service definitions,
but knowing that you need to continue to follow CMS' policy on what needs to be included
in each of those service definitions.
The other thing the informational bulletin does is it emphasizes the critical role
of person-centered planning and achieving employment outcomes.
I think everyone on the phone probably believes and feels the same way that we do here at CMS
and that is that good person center planning leads to a good job and a sustained --
sustaining job, not just any job.
So, the better a job we do with person-centered planning and really getting at the bottom line
of what the person's skills and interest and strengths are, the better the job developers
or the employment specialist or whatever you call them in your state can do
in actually developing a job for an individual.
So, person-centered planning is at the heart of everything that we talk about here today.
It articulates best practices and highlights self-direction options for employment support.
So, we talk a little bit in the bulletin about self-direction as being a really key element
to employment supports for people who want to self-direct their own services.
Employment is certainly a service that could be self-directed for folks.
It explains that the ticket's work outcome and milestone payments are not in conflict
with payment for Medicaid services rendered.
So, that basically means that providers that choose to become an employment network
through the Ticket to Work opportunity can also receive a CMS Medicaid payment for a day
of service without it being a conflict.
And the reason is, because if Ticket to Work is an outcome-based payment and the services
for Medicaid are paid for services rendered.
That attorney input on that and so we've got clarification that that is allowable.
So, if that helps to support you in any way in terms of increasing the finances that are coming
in to your agency by the common employment network, by all means, consider that because
if it -- again, if it's not in conflict at all and we would support it certainly.
It clarifies that prevocational services are not at endpoint, but a time-limited activity
to help someone obtain competitive employment.
And you may notice in the informational bulletin that we don't give a specific timeline.
We leave that up to states to decide, but the bottom line is that it's
up to the individual's person-centered plan
as to how long they would be in a prevocational service.
Gone are the days where people were in prevocational services for 20,
30 years with the hopes, and I use "hope" with a little H of getting a job at the real world.
That's simply not acceptable anymore.
The purpose of prevocational is that the "pre-" means
that there's something else coming that's bigger or better,
and we see that as competitive employment.
So, the purpose of prevocational services is really not that the person gets stuck in limbo
in prevocational services for the rest of their lives and perhaps served
in a sheltered workshop, but rather that they are gaining some short-term goals and skills
that they need to move on to a job and community.
The informational bulletin describes that volunteer work and other work type activities
that are not paid, integrated community employment are appropriately classified
as prevocational and not supported employment services.
So, let me say that again because that's really important
because some states do have volunteer work in their definition
of supported employment, so I just want to remind you.
Volunteer work and other related work that are not paid, integrated community employment,
are prevocational services, and not considered supported employment services.
We recognize that there's an importance certainly for volunteer work.
I think those probably out of the 315 or so of us that are gathered today,
probably the large majority of us spend a little bit of time at least volunteering in the job
or two before we landed our dream job or our jobs that we're currently in.
And so, we recognize that it's very important for people
to have the opportunity for volunteer work.
We just don't want to classify it as supported employment any longer
because the person is not making minimum wage.
So, the other thing that the informational bulletin does is it splits support
and employment into two core service definitions -- individual and small group.
For individual supported employment,
it's expected that the individual will make minimum wage or more,
and that they'll be compensated at the same rate as those individuals
that are not -- that do not have disabilities.
For small group, it's for between two to eight people, and we are looking
at that being a training type of activity, if you will.
That sort of is a jumping off point for someone to get a job,
an individual job in the community.
Again, small group employment is not meant to be a forever type of situation.
It's meant to be a training opportunity that people move on to and move
on to individual competitive employment.
We also added a new service definition for career planning.
We heard from various different associations and stakeholders that they felt
like career planning was an important enough category that it could stand alone
as a service category, or it could be combined with other service categories
such as day habilitation, prevocational, and supported employment services.
So, you can use career planning either by bundling it into one of the other services
that I mentioned, or it could be a standalone service.
But, we felt that it was very important to include career planning in our variety
of services that are offered through CMS because it's obviously career --
good career planning leads to a good job, as well.
So, CMS is not changing policy through this informational bulletin,
but rather we're clarifying and strengthening the guidance around permissible waiver options
to promote employment for people with disabilities and individuals who are elderly.
There's a link in your PowerPoint presentation to the bulletin --
informational bulletin that I mentioned.
And I just wanted to also mention that these changes that were [inaudible]
in informational bulletin will also be included in the 3.6 version
of the waiver technical guide to be released at a later date.
And I can tell you that at this point that date seems to be coming later and later
because we've now rolled out this massive rule on home and community-based services,
which is consuming quite a bit of our time right now.
So, it's coming.
It will come; but in the meantime, you have this informational bulletin
that you can lean on for guidance.
Section 1915 i State Plan Option is an opportunity to provide home
and community-based services for individuals with disabilities.
It was modified through section 2402 of the Affordable Care Act to allow states
to expand access to home and community-based services
without requiring an institutional level of care for enrollees.
So, that's probably the most critical distinguishing factor between in 1959
and 1915 c is that individuals don't need to meet an institutional level of care.
So, far, we have 16 approved 1915 i HCBS state plans, and services include, such services,
for example, supported employment, career planning.
We've seen some prevocational services.
But this is a really good opportunity
for expanding services to the mental health population.
It's a great set for that population.
It allows you to provide employment services and supports for that population.
1915 cs are a little bit tricky when it comes to serving the mental health populations
because there's such a thing called an IMD exclusion that sort of gets in the way
of providing the 1915 c services.
But, not that they're not provided, but we don't see them quite to the same extent that we do
in the 1915 i. So, I would just point that out and the other population
that the 1915 i has been particularly helpful with is the transitioning youth, the --
people with severe emotional disturbance, that particular population,
we've also seen [inaudible] on those as well and that seems
to be a good fit for that population as well.
Medicaid Infrastructure Grant grantees who are working with state
as they develop 1915 i options, you will be talking
with your MIG coordinator if they're still around.
I'm looking at Jeff.
I think they're still around as a result of no cost extension.
To help integrate employment supported policies and supports.
So, we're really -- CMS is looking at every opportunity we possibly can
to integrate employment into all of the work that we do.
So, 1915 i is another example.
1915 j is Self-Directed Personal Assistance Services, or PAS.
It's a state plan option that was effective on January 2007.
It provides a new state plan participant-directed option for the individuals,
receiving services under state plan personal care services benefits,
and/or a 1915 c HCBS waiver service.
Personal care and related services could include home and community-based services
under an approved section 1915 c waiver programs such as supported employment,
and at the state's discretion, items that increase an individual's independence,
or substitute for human assistance to the extent that expenditures would otherwise be made
for human assistance, including additional goods, support, services and supplies.
1915 j, which has been hot in the press lately because it goes along with the 1915 i and 1915 c
and the new HCBS rules that was rolled out recently.
1915 j is a provision of the Affordable Care Act called Community First Choice Option.
It includes a 6% enhanced federal matching fund which a lot of states like to hear.
So, if you're looking for sources of money, here's a source of money for you
to enhance your employment programs.
The 1915 j has to be offered statewide in the community, not in institutions,
and the benefit can be to support individual's employment goals.
Currently, there are two states that are approved --
California and Oregon, and I just got an update today that it's still two.
We have one that's being considered now that's pending, but it hasn't been approved yet.
1115 is a demonstration through Medicaid, and it's for the purpose
of research and demonstration projects.
It authorizes the Department Health and Human Services Secretary to consider
and approve experimental pilot and demonstration projects.
There are many, many states that have 1115s now, and they have been all on the rise.
Many states are looking to collapse all of their 1915 c waivers and move them into an 1115,
or they're looking for 1115 authority, expenditure authority to serve underserved
or unserved populations -- Medicaid populations.
Services may include supported employment career planning and as states are having conservations
with CMS analysts, you will have a conversation --
expect the conversation about employment supports.
Again, we're making sure that we're threading employment through all of our discussions
and all the various different authorities that we offer.
And with that, I'm going to turn it over to Jeff now.
>> Good afternoon, everyone.
It's a pleasure to be with you all this afternoon.
I'm going to be talking about three programs that's there on your screen
and before we do that, Colleen mentioned earlier about the Medicaid Infrastructure Grant.
That grant has ended in 2012 and there was a number of states last year
that after a new contract extension, which ended in December of 2013.
So 44 out of 50 states who started out with the Medicaid infrastructure grant over 10 years ago.
Do you have a sustainability plan in place where the Medicaid infrastructure grant is still going
on at some level, at some capacity in your state?
So, if any of you want to look into your state contacts and to where they are
with the Medicaid infrastructure grants, feel free to contact your representatives.
Okay. I'm going to talk about the Medicaid buy-in programs.
Basically, this program was approved through the Budget Act in 1997, the Balanced Budget Act
in 1997, and Ticket to Work Incentive Improvement Act in 1999.
This really -- this program really gave the opportunity to allow individuals
with disabilities to work and access their Medicaid benefits.
And are more other -- more than otherwise be possible while enrolled
in the traditional Medicaid.
Being able to buy in to the Medicaid insurance while they're working,
so that they don't lose their benefits.
Typically, the states allow the individuals to buy into the Medicaid program
by paying the premiums that are based on their income.
46 states operates in Medicaid buy-in program and there approximately
about 200,000 Medicaid buy-in enrollees nationally, and a high percentage
of them are Medicaid beneficiaries as well,
so quite a few of those people dual eligible for Medicare and Medicaid.
In states that have the option to eliminate income and assets and resource limitations,
it's really depends on your state and how they are set up and they have to amend their policy
through CMS in order to get that approval.
Medicaid buy-in members, they do rely on clinical community long-term care services
such as personal attendant services, global medical equipment and other home
and community-based service to stabilize their health and support employment
through their activities that they are living, which may not otherwise be covered
through their [inaudible] of other health insurance.
On the average the Medicaid buy-in members have lower costs for service expenditures
and individuals with disabilities on a traditional Medicaid,
so it does save some money on a national level.
The next section I'm going to be talking about which is the area of my expertise.
I've been working with the Money Follows the Person program for four years now.
I am the project officer for eight states.
There are four -- currently, there are 44 states, including the District of Columbia
who participate in the Money Follows the Person program.
Originally authorized in Section 6071 of the Deficit Reduction Act of 2005,
which originally provided the $1.75 billion over five years, through the award in 2011.
And when the Affordable Care Act came along, it amended the Deficit Reduction Act
and provided an additional $2.25 billion through fiscal year -- federal fiscal year 2016.
And what happens there, when we get to 2016, which is not far off from now but --
so, any unused amount of money that's left over, which, by the way, is a $4 billion program
when you add the two together, will be disseminated to the states in 2016,
and what will happen is is that they were -- be providing us the projects that will carry them
until 2017, which is -- which will be in December of 2017.
The last day that they can transition someone from an institution to a community setting --
with a year of follow-up at 365 days to 2018.
And then 2019 and '20 is mainly a close-out period to close out the grant.
So, having said that, the Money Follows the Person program does provide numerous
opportunities which states to promote and support employment
through a program administration or policies and services.
States also have an opportunity to rebalance funds
to support employment-related services and activities.
The Money Follows the Person program is what we call a rebalancing program.
It's to rebalance how states are utilizing their Medicaid funds for an individual to --
or institutionalized in nursing facilities and ICF facilities where the major trend --
major [inaudible] projects -- to change the way how individuals who may be
in nursing facilities could benefit much better in a home and community-based setting,
and we recognize every individual is unique and different in many ways depending
on which services that is needed for them to be successful in the community.
The Money Follows the Person program has several state investments using rebalancing funds.
What that means is the rebalancing fund, the amount of transition that the individual --
the amount of transition that the state accomplishes,
the difference between the facility-based cost versus home and community-based cost,
there's a savings in between there and that's what's called rebalancing fund.
It's the amount of money states are saving
when they're transitioning individual data [inaudible] into the community.
And that is what's called -- we call that state money.
It becomes state money but they can only use that so-called extra savings
when they transition someone from the facility into the community.
And that allows unique opportunities for states to increase waiver slots
where there might be a waiting list in many areas [inaudible] rebalancing funds kind
of release that waiting list and allows opportunities to allow for more slots.
It also allows for development of needs assessment tools
and increasing community service capacity including employment services.
Colleen mentioned earlier about employment being on the radar and,
yes, it's very much on the radar.
It's a very hot topic right now here at CMS.
And we're now collaborating with Serena and her staff at ODEP.
We're really trying to work together as a team to share information and to share ways
to increase employment outcomes for people with disabilities.
The Money Follows the Person program does employ the opportunity for a state
to hire employment specialists on staff, benefits counseling,
the support employment home community-based services specialist.
And there -- on the slide, you'll see that there is a web link that has our employment policy
that we have created within the MFP program that kind of lines up what MFP can pay
and what the home and community-based services can pay,
and it kind of cross each other systematically to kind of share resources.
So, when you all have a chance to take a look at that policy and feel free to contact us on that.
Going to the next slide.
The next program I'm going to be talking
about is another grant program called Balancing Incentive program.
I'm not an expert in this area, but I'm here to share the information.
At the end of the slide, there's contact information,
an individual who's the one there, is Effie George.
She is the project officer along with [inaudible] who is also working with Effie
on the Balancing Incentive program.
So, I'm going to share our information, so if anybody have any questions,
I'll do the best I can but I may not --
we'll currently be able to take the questions and get back to you.
So, [inaudible] the Balancing Incentive program authorizes CMS
to provide financial incentives to states.
Its [inaudible] the goal to increase access
to non-institutionally based long-term services and supports.
The participating states are required to make the following structural reforms in the areas
of no wrong door, single-entry point system; conflict-free case management;
and core standardized assessment instruments.
Total funding is not to exceed 3 billion in federal matching payments.
The Balancing Incentive program also transforms long-term care systems [inaudible] program
actually started in 2011 and it has a variety of areas that will lower cost
through the improved systems performance and efficiency, and helps creates tools
to help consumers with care planning and assessment,
along with quality measurement and oversight.
The Balancing Incentive program also provides new ways to show more people in home
and community-based settings, and keeping with integrating mandate of the Americans
with Disabilities Act as required by the Olmstead decision.
And regarding the Balancing Incentive program as well as some technical terms here,
but really it is to help make structural reforms to increase nursing home diversions and assets
to non-institutional long-term support services.
And the [inaudible] the states are getting enhanced match and they are tied
to the percentage that the state long-term support service's spending mechanism
with a lower [inaudible] the increasing [inaudible] states will help make fewer reforms.
Total funding over four years from October 2011 to September 2015 cannot exceed 3 billion
in federal enhanced matching payments.
And there, the website that included on there that [inaudible] get insights
and certainly you can email us for any questions.
The next area I'm going to be talking about is support employment for people
with significant mental health conditions.
Basically, the current picture here as we see it is that people
with mental illness have unemployment rates beyond 80%, yet more than two-thirds report
that they are -- that they want to work.
Day treatment and psychosocial rehab services comprise a significant percent
of state mental health spending.
Virtually, there are state mental health spending on day services.
And according to 2011 SAMHSA data, only 1.7% of the people serve
as state mental health agencies receive any type of supported employment services.
There's a benefit design in this area.
The description, there's a typical service components including assessment,
supportive counseling, benefits planning and assistance,
job development, and on-the-job supports.
And the case for supported employment to the -- that you see on your screen,
there's a variety of bullet-point areas that plays a major role for supported employment.
As many of you may know, but we're certainly --
we have a highlighting on this screen is improvement and mental health functioning,
improved clinical outcomes, reduced use in-patient psychiatric admissions,
reduced use of psychiatric crisis services, increases attendance
at regularly scheduled mental health appointments, improved employment outcomes
as we all like to see that as currently a key role with --
for individuals I think for any disability
and having an employment outcome makes a huge difference.
Higher rates of placement in competitive employment, higher salaries,
creates an opportunity for a higher number of hours work, higher rates of job retention
and higher levels of job satisfaction.
So, that concludes what we have for today and, certainly, we are --
we believe there is a question-and-answer session.
And Serena wants to jump in to see how we can go from here, we'll be glad to help you out.
>> Absolutely.
I just want to thank Jeff, you and Colleen again for a very thorough
and comprehensive presentation and overview of a number of state waiver and plan options
and other initiatives that states can take advantage
of through their state Medicaid agencies and supportive sub-agencies
to really promote integrated employment options for individuals with significant disabilities.
So, that was a wonderful overview.
We are going to jump right into our Q-and-A session.
In order to preserve the quality -- sound quality of the phone,
we will be taking questions via the chat feature.
So, those of you that registered for today's webinar and are participating
as you have questions, please feel free to submit them.
Many of you submitted several questions during the registration process, so I have several
and I'm going to take the liberty of just facilitating a conversation with Jeff
and Colleen based on those questions first.
And then as other questions percolate, we'll take those, as well.
One of the first questions that we had and I'm going to kind of scatter all over the place
so that we are able to capture diverse interest, in the various options
and initiatives that you all spoke to.
We did receive a number of questions on 1915 c and so I'd like to start with one
that was our first question, which is, "How can states comply with federal regulations
and simultaneously adopt a policy of no new entrants
to facility-based prevocational services for existing 1915 c waivers?"
Colleen, can you take that for us?
>> Yeah, I'll take it and I'll punch it [laughter].
Actually, it's -- that's an area that we're looking at.
We've had so far one state has come into us with a proposal to do just that and that is
to close the front door to all new entrants.
In, particular, this one state is -- has closed the front door to shelter workshops
for transitioning youth, which I think was a very smart strategic move on their behalf.
But, we're trying to figure out policy-wise how we can make that happen smoothly
so that it doesn't become a waiver within a waiver.
So, for example, all waiver services must be available to all waiver participants.
So, by saying that certain participants can't participate in prevocational services or --
and that service is typically offered in the shelter workshops, then you are excluding
that group from being able to access the services.
So, we are looking at the policy on how to make that happen,
and I am guessing that the policy will come out relatively shortly
because obviously we have home and community-based settings rule that's hot
on the trail that will be effective on March 17th.
And folks are going to guidance on that.
So, we are working on that but we're just not at a point where we're ready
to give folks guidance on that just yet.
>> Great. "So, for states that are looking at that, would you recommend that they reach
out to CMS or to have a conversation in advance?"
>> Yes, definitely.
And I'm always open to having states contact me -- state employment coordinators contact me
and talk with me about their ideas for what they want to do with their employment services.
So, if you're grappling with, let's say, offering career planning as a standalone service
versus bundling it in with other services, I'm happy to have that conversation with states.
Sometimes it helps to just talk through your ideas and to know that CMS is supportive
of your ideas before you put them down in writing and then submit it to us for approval.
>> Wonderful.
Thank you for that.
I'm sure there are many enthusiastic participants on today's webinar
who will take full advantage of that opportunity.
One of our next questions is something that comes up quite frequently in a number
of our conversations on -- from ODEP's standpoint,
and it's related to personal care assistance.
And we have a question here from one state.
They're very interested in getting some clarification and even some ideas
on creative strategies that states are using to allow personal care assistance services
to assist people in the workplace.
Could you share some light on that as well?
>> Sure. I've seen some examples of personal care assistance being used in addition
to a job coach for the purpose of personal career task.
So, for example, the personal care attendant may go to the individual's home,
help them get prepared for work for the day, you know, help them get dressed, help them get up
and help them access the transportation that they need to get to work.
And then, meet them on the job site at a later time, let's say, at --
like 12 o'clock, 11 o'clock, 12 o'clock or whatever, for a break, you know,
a bathroom break, feeding that needs to occur and changing that needs to occur,
positioning that needs to occur, that kind of thing.
So, we have seen some of that in waivers.
>> And that's completely allowable by CMS, correct?
>> Yes, that's allowable at CMS.
>> Great. Our next question...
>> Serena [inaudible] that it can be a component of a certain service,
like a prevocational service for supported employment service,
but it can't comprise the entire service.
So, you can have as part of your --
let's say, for example, it's a supported employment service.
You could have a subcomponent, personal care attendance services for, you know,
X amount of hours of the day, and then job coaching services
for X amount of hours of the day.
It gets a little tricky when states have daily billings because then it's not as easy to break
up the day into different billing units.
But, it certainly can be done from a policy perspective.
Okay.
>> That's very helpful.
Thank you for clarifying that.
Our next question is with respect to career planning, and I'm just going to read it from one
of our participants from the great state of Iowa.
"I understand career planning services would include discussions, assessments,
etcetera, to identify one's career plan.
But can career planning services also include financial planning services,
work incentives advisement, etcetera?"
>> Certainly.
States can build their services to include just about anything under the other category.
And career planning would be a service that falls under the other category.
So, you could absolutely build
in work incentives planning into that particular service.
And also, work incentives could potentially be a standalone service
that states offer in their waivers.
Although, I have to say that we will ask the questions,
is it available through other means first and foremost such as
through the WIPAs -- the local WIPAs.
But, if it's not available, or if there's a lack of resources, then by all means, work --
financial planning's and work incentives planning could certainly be considered a 1915 c
service within career planning or as a standalone.
>> Thank you for that.
That's very helpful.
Another question that we had was with respect to the infusing or braiding of resources,
HCBS services and resources across systems, and this --
in this case with respect of vocational rehabilitation.
Can you help -- can you discuss a bit how HCBS services can support and integrate
but not supplant VR services and how you've seen that interplay with various states?
>> Yes, and let me tell you that that's the $10 million question, how to do that successfully.
And if we had the answer to that, I don't think any of us would need a job.
And it's interesting because Jeff comes from the VR system and I come from the IIDD system
and we work collaboratively and we put our heads together and can't figure it out either.
But -- no.
All kidding aside, the purpose of VR services as I understand them and Jeff will correct me
if I'm wrong, is to provide the short term upfront job coaching and job development
that a person might need to obtain the job.
The purpose of 1915 c or 1915 i services would be the long-term sustaining
of a job -- sustainability of a job.
So, VR should be used upfront first and foremost, and then there's a handoff, naturally,
to either the IIDD system, the mental health system, or any other system
that is providing employment services to people long term,
to provide the long-term job coaching.
And I can give you an example of a best practice that's out there that the best one
that I've seen so far in my career at CMS and it's not just because I'm from Maryland --
and hi -- a shout-out to all my Maryland friends out there.
But the Maryland VR and mental health system have a really good working relationship.
They even share a database, a computer database, whereas it's a single point of entry.
Folks can access either or service by entering that portal,
and then there is really good tracking of who's paying for what.
So, who's paying for job coaching on any given day and who's paying for job development
on any given day, etcetera, etcetera.
And, again, that's through the Mental Hygiene Administration at the state of Maryland,
and the VR Department in the state of Maryland.
In fact, I know that there was a paper that was written and I apologize
that I don't have the citation for it.
But perhaps if you Google VR and mental health systems,
you might be able to come up with that paper.
The contact person in Maryland I know, he'll shoot me if he knows that I'm spreading his name
around is Steve Reeder -- R-E-E-D-E-R.
And he's the person that really put his heart and soul into creating that program.
So, he's very knowledgeable and I'm sure he would be happy
to share his expertise with folks.
>> We have -- we also have an adoration club over here at ODEP of Maryland's system,
and of Steve Reeder, in particular, who's the subject matter expert for us on our Employment
for State Leadership Mentoring program.
But we also have that citation and so we can send around to folks
who are interested in that and learning more.
The next question I have is related to the Balance Incentives program grants,
and so I'll turn it over to Jeff for this one.
But for the BIP grants, how are they supporting employment systems change
from facility to community-based services?
It seems to me that all these employment services are already under the HCBS side of BIP.
Can you all help clarify for us?
>> The fact that my understanding is, the way the Balancing Incentive program works is,
number one, it's suppose to bring down the Medicaid spending,
for state's that are spending over 50%.
It's supposed to bring down the level of spending.
As far as the -- and I know that's not the answer you're looking for,
but I think in relating to the question whether or not they are connected to HCBS [inaudible],
BIP is really supposed to be a mechanism to assist with any areas that may not be covered
and I'm not saying -- and I might not be saying that in a right manner,
but that my understanding is, it's really to help facilitate states on the areas of the
"no wrong door" and the career planning aspects of it.
And I think if you go on to the websites, there is a question and answer area and if we can't --
to really be honest with you, I don't have an answer for that.
I don't know off the top of my head because it's really not my expertise area.
But, if you can -- I can get this question answered through Effie and Carrie
who runs the BIP grant and I can certainly -- whoever --
[inaudible] the question on the screen.
I'll certainly be glad to get that answered for you.
>> Great. And then follow-up to that, I know that one question that we get a lot or interests
in is states who are looking at the BIP or who are already receiving a BIP grant.
They're very interested with in terms of its correlation with employment, looking at how some
of the structural reforms that are required under the BIP can be used
to help support their employment transformation efforts.
And one of the key structural reforms, I believe, Jeff, is that the state has
to introduce policies to promote conflict-free case management across the boards
so that individuals aren't being counseled about their options from the same folks
that are providing the services and it kind
of creates some independent and ethical processes with that.
And so, when we -- when you follow up with them and often these have these questions along,
it would be great to get some additional clarification or information on strategies
that that existing BIP grantees have put into place to really make sure that on the employment
and day side of service delivery that's financed through Medicaid
that there's a conflict-free case management protocol in place.
>> I could tell you -- this is Colleen.
From my perspective, I've worked with a couple of BIP states and Effie George,
who is the BIP project officer, will bring up employment as part of the dialogue,
absolutely as part of the dialogue for states that are investing in --
or reinvesting in, I should say, community-based services.
So, you can expect to have that conversation with Effie and/or Kara depending
on which project officer you reach.
That's just as part of this conversation that we're having when we're talking
about the institutionalization of people, we're not going to talk through about where they live,
we're talking about where they work, as well.
>> Great point.
Excellent point.
Another question we have is around the topic of transportation and we know at ODEP
that this is a really an ongoing challenge for states grappling with trying
to ensure full wraparound supports for individuals and to ensure their ability
to participate in integrated employment and other aspects of life, so of community living.
So, the question is as follows.
Transportation is a big issue for getting people to and from their jobs.
Can we continue to have travel reimbursement for those
who are needing assistance with transportation.
Can you speak a little bit to how the different waiver and plan options can be used
to support the transition needs or the transportation needs
of individuals with disabilities?
>> Sure. The -- within the waiver oftentimes people link transportation with the service
that they're providing, so if you receive day habilitation or prevocational
or supported employment services, transportation is part of the rate.
That's not always the case.
Sometimes, states provide transportation as a separate service outside
of a bundle, which is fine as well.
The other thing that we've seen some states get creative with is paying for bus vouchers,
paying for taxi fares, you know, people -- and who are self-directing could pay a neighbor
to provide transportation for them to and from work, or,
you know, a coworker, etcetera, etcetera.
I think the thing that you have to be careful with is
that the provider is not billing the individual for transportation
and accepting Medicaid payments at the same time for transportation,
because once you accept the Medicaid payment, it's a payment in full.
And if it includes transportation in the rate,
you cannot bill individuals separately for transportation.
So, I just wanted to throw that in there because I know that that happens in states sometimes.
>> Boy. That's a great cautionary note for a lot of folks both states and providers of services,
many of whom are on the phone, as well as disability advocates.
So, thanks for making that clarification.
I want to talk about outcomes for a little bit, as I -- as we have talked behind the scenes,
I know you guys are getting a lot of great questions about whether or not rates can be tied
to some type of performance-based tiered payment system or outcome system.
So, we received a question that I think really speaks to --
can raise be developed based on outcomes such as quantity of work achieved and amount
of employer-funded benefits received.
I know you guys that this is an ongoing dialogue for you internally,
but could you speak a little bit to the issue around for states who are wanting to try to tie
and attach their rates or payments to specific milestones or outcomes?
>> Sure. This is an ongoing question that's becoming more and more popular,
which actually we think is a great thing.
As you know, Medicare pays for outcomes.
Medicare billing is very different than Medicaid billing where we're paying for a service.
However, there is some wiggle room within the current CMS technical guidance,
policy in other words, that would allow a state
to build the rate structure that is outcome-based.
You could do it through a number of different ways, either you could have the service
and let's use supported employment as an example.
For supported employment, you may have an outcome that is a career plan is developed.
So, you have a career plan in hand.
You get a milestone payment for that.
A job is developed.
You get a milestone payment for that.
The person increases their work hours.
You give them a milestone payment for that.
They increase their earnings you give them a milestone payment for that, whatever.
I'm just throwing out random outcomes that could be possible.
You could either bill that as subcomponents underneath your supported employment rate.
So, for individual supported employment, under that particular billing code,
you would have subcomponents that would list out the various different outcomes,
or you could also bill the outcomes under supplemental payments, which is an option
that is in appendix I of the waiver, and you could bill us the -- bill them as support --
I'm sorry, supplemental payments.
The one cautionary thing that I want to throw out there to the wind here is
that when states are coming in to CMS with proposals to pay outcomes versus services.
We're going to ask some really hard questions about what are your qualifiers,
what are the quality standards for each of the outcomes that you've established.
You know, what has your state looked at in terms
of can it be any job that a person gets, for example?
Or does it have to be a job that the person is interested in, or that the person chose?
Does it -- can it be any wage?
Does it have to be minimum wage at a minimum?
You know, that's a qualifier there that has to be minimum wage or higher.
So, we're going to be looking for you to give us a proposal on how you're going to lay
out the program pretty specifically, in terms of providing an outcome-based payment system.
It's not just as simple as listing the outcomes one, two, three, four.
We want to know how did you get there.
What kind of conversations did you have to bring you to the point
of selecting those particular outcomes over other outcomes
and what qualifiers did you discuss?
>> Great. Thank you for that.
I think there's a lot of states that are really interested in this, but as you know better
than anyone, it's a very complex effort to do this
and I think folks will need some additional opportunities
to get feedback from CMS along the way.
So, thank you for that.
The other thing that -- one question we had is that on your slide eight,
and let me see I'm not really sure what that one is, hold on a second.
On slide eight, related to the 1915 c waiver technical guidance revisions, I think --
but it's on -- it mentioned other work activities that are not classified
as supported employments, if not paid such as volunteering.
And in this instance, this is a --
coming, I believe, from a provider that we typically conduct 20,
30 hours of community-based work assessments which are unpaid.
Does this mean they will no longer be funded?
>> No, we're not saying that it [inaudible] funded.
We're saying that it's no considered supported employment.
>> Right. I'm sorry.
I -- there was a break in the question.
That's what she wants to know is that --
so they currently receive reimbursements for an under-supported employment,
but you're saying moving forward that they would not be funded under supported employment,
but they'd be funded as maybe a separate service.
>> Yes, it's pretty vocational most likely.
>> Okay. Great.
Thank...
>> Vocational or possibly small groups depending on the sides of the number of people
that are working on that, but, yeah, assessments which fall under prevocational activity.
>> Wonderful.
Thank you.
Okay. Shifting gears a little bit to Money Follow the Person,
we have a participant here who'd like to get a little clarification
about what Money Follows the Person can pay for and what the waiver can pay for
and how those are distinguished in a state that has both.
And where does IVRS come in?
I think you've answered the last part of that question, Colleen,
but I'm wondering if you and/or Jeff have some thoughts about for --
or guidance for states that really want to maximize both their waiver options
and their existing Money Follows the Person program
to promote integrated employment outcomes.
>> Well, coming from the MFP side, basically, when we're working
with individuals who become MFP, it just depends.
Number one, during -- they're coming from an institution to begin with,
that's how they're eligible and on Medicaid.
We have two project areas.
We have a demonstration service and we have a supplemental service.
The demonstration service is the area where it's what Medicaid pays
that is allowable within Medicaid services-wise.
Whereas with supplemental, it's not -- it's an area where Medicaid doesn't cover it,
but the MFP program won't be able to cover it.
For example, and this is just an example.
When we're transitioning individuals to an apartment or to a home, usually,
they need a post [inaudible] of funds.
Well, Medicaid doesn't pay that, but MFP can pay that.
So, the uniqueness of the MFP program is that I'm not going to say we can pay
for everything that Medicaid does.
And for the majority of the unique circumstances that do come up, there are quite a bit of things
in there that we can pay for that Medicaid doesn't because we have to make sure
that the individual is being able to transition in the community to [inaudible].
That's the uniqueness of the MFP program because it's a demonstration.
It's to show what the services are needed for an individual in the community
if they can get everything that they were getting
in the institution purchase in the community.
And it also depends on the level of care going out into the community.
I don't know if that actually answers the question to what --
but I know when individuals transition out into the community, we follow up --
the states follow up for 365 days after the first day of transition.
But before they transition, they have to --
the states have to make sure that their waivers are available for that individual
to transition to, because otherwise the transition will not occur
without the waiver support being in place.
So, I think it really depends on the state's waiver applications
as to what they have in the state waiver areas.
I mean, they may be serving, for example, some place have several waivers
and they're serving the physically and disabled population
or they're serving the elderly population.
So, at the state by state to what their waivers are --
at their state capacity and what they are willing to pay or able to pay.
And I don't know if Colleen can chime in more on the waiver side.
But that's how it works with the MFP is that they don't --
no one transitions into the community until the individual has been confirmed
through the waivers [inaudible] to the waiver program.
>> Jeff, I think -- that I think -- thanks for clarifying that and I think I --
most people on the phone are aware of that element.
I think what the question might have been attempting to ask and something
that we get asked a lot is for states who are -- who have a Money Follows the Person program
and they receive -- they're into the program, they're starting to have some success.
How can they leverage those resources to support the employment goals of those individuals,
and do that instead with whatever waiver supports and, you know, an individual
or group individuals are already receiving.
We know that there are some -- we know there are states that have had some good success --
or limited success with using the MFP resources to help promote employment,
but I think these are really interested in hearing about those successful strategies.
So, are there resources or information that CMS could provide on some of those examples?
>> Yeah. It's actually on the slides.
There's a -- I forgot what slide number it is, but it's on the slide where I talked
about the link on there that there's a comparison between MFP employment support
and the waiver employment supports.
And it aligns what MFP can pay for and what the waiver can pay for.
For example, if someone would need to go into the community and they need a home modification,
they need a ramp, or they need a [inaudible] application, you know,
they look at in the MFP portion to see what can be done to make that work.
And utilize and other resources while there is -- whether or not it can be through the waiver
or whether or not it can be through the assistive technology program, the, you know --
so there's other resources, even including the VR program who may be able
to play a role into that area as well.
As far as job coaching support and job supports, we're really relying
on the waiver community supports through the information bulletin that talked
about the job coaching support aspects of that.
I don't know if that quite answers that question.
>> That's helpful.
Thanks, Jeff.
Colleen, did you have anything else you wanted to add?
>> I just wanted to just, I guess, reemphasize that the list that Jeff is talking
about gives examples of how states have used the rebalancing money
to support individual employment outcomes.
>> Yeah, good point.
Colleen, the rebalancing fund.
That's the fund where states are collecting money, so to speak, through the savings
when they are transitioning individuals from the institution to the community.
There's an amount of money that's being saved for the state and that amount
of money is actually translated at the rebalancing fund.
The rebalancing fund is technically state funds, but the state has to report
to us how they are using that fund.
For example, we -- it's emphasized in our policy that the rebalancing fund cannot be used
for roads and bridges and other state infrastructure.
It must be used with the concentration in the home and community day services.
So, if an individual has been transitioned out into the community, and some time has gone by,
and they need some other assistance in the homes that would not necessarily may be picked
up early on, or was developed later on that something has occurred
and that they need assistance in the home, that the rebalancing fund can play a role
to help maintain the individual to remain in the home [inaudible] can be re-institutionalized.
So, the rebalancing fund is a very unique avenue of funding sources that could be used to keep
and help the individual maintain their independence
in their home at whatever service is needed.
>> Great. Thanks so much, Jeff, for that.
A couple of additional questions, but before we do that, I want to just jump back
to the outcome-based payment strategies and milestone payments.
Colleen, can you clarify if states are interested in including job coaching as part
of a milestone payment or tiered payment, outcomes-based payment process similar --
for example, Oklahoma has a pretty interesting outcomes-based model
and job coaching is a part of that.
Is it your impression that that's -- would be an allowable or an appropriate milestone or outcome
to have in a tiered payment structure?
>> Yeah. We'd have to really look at it on a case-by-case basis, but unfortunately,
Oklahoma isn't a good example to share in just for the mere fact
that they didn't specify how they're doing their outcome payments in their billings --
I'm sorry, in their waiver application.
So, you know, it's not like I can point you to Oklahoma and say,
"Look at their waiver application.
The language is in there."
It's a good example.
It's not written in the waiver application, so I can't really point to that as a best practice.
But, it -- you know, again, just in general of late, we have come to the understanding
that it's really important to be able to force states to pay outcome-based payments.
And so, we're looking at various different ways that we can allow that to happen
within the current regulations, statute and guidance that we have.
>> Great. Thank you.
We have a -- we received a question from one of our participants related
to Ability One contract jobs that individuals
with significant disabilities may be participating in.
The question is, does CMS recognize Ability One jobs whether they be service or product oriented
as integrated employment and can waiver money be used to support these jobs?
>> CMS does not take a position on Ability One contracts.
We simply don't want to get in the middle of Department of Labor work.
That's really Department of Labor's area of expertise and so we don't want to dabble in it.
It's up to the state to look at the criteria that are listed in each
of the different core service definitions and determine
which category Ability One fits in best.
And it could be that Ability -- an Ability One contract for one provider looks very differently
than Ability One contracts for another provider.
So, for example, a perfect example here in the state of Maryland,
I know that we have some Ability One contracts where individuals are cleaning buildings
when the buildings are closed and there are no employees in the building, and therefore,
they're not integrated with individuals without disabilities, versus an Ability One contract
where they're cleaning the airport, where there are face to face interactions with people
without disabilities all the live long day.
No matter what hour of the day you go to the airport, there are people without disabilities
that are in the airport that people are interacting with as they're cleaning.
So, it's really up to the state to make the determining factor on a case-by-case basis
which Ability One contracts will fit the bill for supported employment
versus group supported employment, versus prevocational services.
>> Thanks so much for sharing your perspective on that, Colleen.
That was most helpful.
We also have received a question for you all.
Can -- what are some creative ways or approaches that states are providing
for meaningful wraparound supports for individuals who may be employed less
than full time, but does not include spending part of the time
in a segregated day habilitation or segregated prevoc services.
>> That is the question of the day.
There's going to be much more guidance that's going to come out on that and follow-up
to the HCBS rule that will be effective on March 17th.
We have a nonresidential workgroup that is working on providing sub-regulatory guidance
and Jeff and I are both on that workgroup, where we'll be providing examples of places
that may meet the home and community-based settings criteria and those that may not.
And what some of the individual criteria are for looking at each individual circumstances
to determine whether or not it's the most integrated setting for that particular person.
Did that get at your question?
I'm sorry.
I might have gone off track.
>> No, that's perfect.
It does. And for states, I'm just --
I think this was brought up by a state who's probably thinking sooner than later
about proactively including any strategies or thoughts into an upcoming
or imminent waiver renewal application.
And so, do you have any examples to date of states that are kind
of maybe proactively infused some strategies through their waiver or state options
that you would -- or state plan options that you would highlight?
>> You know, at this point, we are at still in the information gathering phase...
>> Sure.
>> ...and we got recommendations.
We got -- we spoke with multiple different stakeholders as part of our work
on the non-residential workgroup.
And they offered some suggestions for best practices of particular states and/or providers.
And we feel like it wouldn't be in the best interest of anyone for us
to simply just pass along the name or the state,
or provider to individuals without us researching it first.
So, we're looking into how we can get really good evidence-based practices information
out there in the hands of providers.
And I can tell you that some of the services that I've seen personally in my going on around
in the country, are settings where individuals are in the community when they're not working,
spending time either sharpening their work skills, sharpening their social skills,
sharpening their independent living skills.
They are exploring other job opportunities that may meet their interests better.
They are volunteering.
They are spending time doing what you and I would do if you and I were all
of a sudden tomorrow to become unemployed.
What would we be doing?
And I would dare say that we probably wouldn't be bowling for very long
because bowling doesn't pay the mortgage.
Now, bowling may be appropriate for some people.
That may be the social activity that is appropriate for someone.
But, people who are of working age should be focusing on work-related activities
to the extent that it's appropriate for the individual and, again, I'm going to go back
to the person-centered planning because I think that it's so critical in all of this.
But, you know, there are programs that are out there
that are doing [inaudible] therapy and we know that.
There are programs that are out there that are sending folks to bowling alleys or to malls
to do mall walking all day long, and we know that.
They are not necessarily best practices
and we would not probably promote those types of programs.
If they are a program where the individual is, let's say, meeting in the morning at a bakery
with a couple of friends that they like and that they choose to go to the bakery with,
and then from there, their spattering out and going out and doing different things
that meet their specific interests that maybe one is going to volunteer at a soup kitchen,
one is going to work out at a gym, one is going to a doctor's visit, you know,
maybe one person is going to a part-time job and then maybe those folks gather back
at the bakery later that day or they gather at the library later that day.
But, it's about the community, being in the community doing community-based activities
that people without disabilities are doing.
That would be considered a best practice, I can tell you that just off the record because I have
to come out and [inaudible] Jeff but I think that we all here at CMS believe
that that would probably be a best practice.
>> Fabulous.
Thank you for that.
A couple of other questions.
"Can you give any insight to the Medicaid billing process for fee-for-service states?"
>> Can you repeat that again?
>> Sorry. It is, "Can you give any insight
to the Medicaid billing process for fee-for-service states?"
Is that...
>> I'm not really sure what that means.
>> Yeah. I had it at the end here because I wasn't real sure either if it was applicable.
>> I'm sorry.
I'm not real clear on what that means.
If the person that asked the question could give us more details, that would be really helpful.
>> Great. Okay.
We will follow up with them.
Another question, "What kind of -- so, one of the big, I think, concerns that states have is,
you know, is their transitioning the focus of the types of services they're financing
to ensure that people are receiving services in the most integrative setting.
How -- what kind of steps or assurances do they need to take to ensure that these individuals
that are being transitioned from, perhaps the segregated settings whether it be segregated
work, or segregated prevoc, or day hab, will have complete access
to qualified employment vendors who actually know how
to help them achieve integrated employment in the community?"
>> I think that that is a top challenge for the states, each individual state,
to develop that capacity for really good qualified providers.
You know, CMS looks for an assurance that the states are providing good qualified providers
and that they are meeting the standards that they've set --
that the states have set themselves for ensuring
that the providers are meeting certain qualifications.
You know, it's a tricky one.
It's a tricky one.
I think that a lot of it comes down to good training and technical assistance.
I know it's an area that ODEP is focused on.
It's an area that we intend to focus more intently
on in the coming years as states work on the HCBS role.
But training is really the key and you can't simply hire someone and send them
out into the field to do good work and expect them to do good work.
They need to be mentored and really shadowed for a while before they can be cut loose
and expect to do a really good job.
>> That's a great point, Colleen, and as a follow-up -- it's kind of subquestion of that,
could you speak a little bit
to the individual-supported employment service definition
that was in the 911 or 91611 bulletin?
And some of the things that's allowed there such as customized employment strategies
and other things, just so that states really have some ideas for how they could utilize
that service definition to encourage and incentivize providers to focus
on developing expertise and key practices.
>> If I understand your question correctly, I think what you're asking for is what are some
of the best practices in providing employment supports that could be provided to a provider --
through a waiver that may not necessarily cost money.
>> Well, not that it may not necessarily cost money, but that would be allowed
under individual-supported employment services under the waiver.
>> [Multiple speakers].
>> Yeah.
>> Let's see.
So, for example, coworker supports, is that an example of what you're talking about?
>> That's an example, yes.
>> [Inaudible] okay.
Good. I'm on the right track then.
Coworker support models are a really good resource for states to use
to expand the capacity of job coaching.
So, coworker supports are supports that are provided by a coworker
that does not presumably have a disability that works in the same workplace
as the person that has a disability.
And they are basically responsible for sort of assimilating the individual into the workplace,
you know, inviting them to lunch, showing them where the lunchroom is,
showing them where the punch-out clock may be, that kind of thing.
It's a job coach's responsibility to actually teach the individual their job and then
to link the person to someone like a -- either a natural support,
which would be the ideal situation where you're not paying for them,
or a coworker where you may pay the coworker at stipend for pay --
for providing the support that I just talked
about like making those natural bridges -- bridging that gap.
Coworker support models can be funded through the waiver and you could use it, again,
as a supplemental service or you could use it as a subcomponent under supported employment rate.
And I've even seen some -- there's one example and I'm sorry
that the states escape me right now.
There is one example of a state -- I want to say it's Oregon --
that actually has a coworker support service written into their waiver.
And I'd have to look at -- look up that information
so I'm giving you the accurate information and then the exact waiver.
But, there is a waiver that has coworker supports
as a separate distinct service, which is pretty cool.
>> Great. Thanks for that, Colleen.
And, there's other practices as well, [inaudible] like discovery
and customized employment services, I'm assuming...
>> Sure, yeah.
Customized -- you know, I get hung up on the words here
because Maryland called it the opposite of what it actually is, what it's customized employment.
But, customized employment is a really good strategy that works particularly well for people
with very significant disabilities.
It's really matching the individual's strengths and interests to the needs of an employer
and making a really good job match, just like job carving in the old --
in the '80s and '90s, we used to call it "job carving,"
but that's basically what it is, customized employment.
It works really well for people with -- and particularly with significant disabilities,
those that can't speak for themselves, perhaps,
or have physical disabilities and have trouble communicating.
Self-directed models, or another model that work really well for employment supports.
So, instead of hiring a provider, and, providers, all close your ears,
the individual could hire the next-door neighbor, or, you know, the --
a coworker at an employment --
place of employment, to provide their job coaching for them.
It could be done.
It has been done.
It is done now today.
So, self-direction is a really good model that people should take advantage
of if they have the opportunity and supports to do so.
Peer support is an excellent model for -- particularly for people with mental illness,
but not just for that population.
Let me be clear about that.
Peer support is just playing a good model.
It's peers that are training other peers and it works well.
For example, when I started working at CMS, I was assigned a mentor
who was a peer, who really showed me the ropes.
They showed me around the job.
They showed me where the cafeteria was, where the post office was, blah, blah, blah.
And I could go to them.
They were my go-to persons for all things brand new to me in the world of CMS.
That's a peer support and that's a support that's not paid.
But peer support sometimes can be paid, and let me be clear about that.
It is allowable to be paid on the waiver, but sometimes it's not
and it's just a natural support and it's a wonderful support.
So, those are some examples.
I, of course, would be remiss if I didn't mention self-employment.
Self-employment is a wonderful option, particularly for people
who have significant disabilities who a typical job may not work well for.
I've worked with a number of people with autism that just had difficulty working
around other people and in environments -- in busy work environments.
And, you know, I could think of one example of a guy that set up a print shop with the help
of his high school teacher, and then from there he continued with that print shop job
after his high school career was over.
And he continues to this day printing all kinds of t-shirts, and mugs,
and hats, and you name it and he does it.
So, sub-employment is a really good option as well for folks to consider
that sort of, not the ordinary, if you will.
>> Those are some wonderful examples of effective practices, Colleen,
and I really appreciate you spending some time --
given us your sense of some key effective practices.
I think that was really important for all of the participants to hear,
especially those that are intimately involved in their states, waiver,
renewal application process, or state plans to really think
about how to infuse those strategies.
So, thank you so much.
That was excellent.
>> Serena, this is Jeff.
If I can add two quick things here.
Yeah. I failed to mention earlier in my presentation in regarding MFPs.
Just so folks on the call know that as of December of last year, December 2013,
we have transitioned a little over 35,000 people since the start of the program 2007.
It may sound like a low number, but it takes several years for a state
to get their infrastructure in place.
And it really picked up within the last two years.
We really gained momentum and transitioning folks in the community.
That's the one point I want to make.
The other point is regarding the BIP, the Balancing Incentive Program.
Two areas I just want to clarify and we can go two ways with this.
For states that are on a call that are aware
that you know you have a Balancing Incentive Program, I would strongly encourage you to --
if you don't know who the project director is handling the grant,
it's to be able to find it on the state's website.
They usually post that kind of information.
If for some reason you can't locate that information, please let us know that --
the reason I'm suggesting that is that you can always go to the project director
and ask the Balancing Incentive questions that you have.
And also, utilize Effie George and [inaudible], but mainly Effie George,
[inaudible] this is just an idea and I'm not speaking for Effie here
but maybe something worth similar to this call if you want to coordinate something,
if you have a strong [inaudible] from the states, meaning, some kind of a little bit
of an orientation or something regarding to BIP and how it relates
to all the system transformation.
I'm sure Effie won't mind coordinating that and be glad to be of assistance,
but that we can communicate with her and I can help you with that.
>> That would be fantastic.
I think we would welcome that opportunity.
You guys are doing so many great things, it's hard to get all the --
that your good information into one call.
So, we absolutely would be -- would be delighted
to host some additional webinars beyond this two-part series.
So, I'll definitely be following up with you on that
and I appreciate you not only making the offer but signing Effie George [laughter].
>> I mean, we'll work together on that I'm sure it's scheduled, you know,
but it may take time to schedule that.
But it is important for stakeholders and providers to understand the connections
with the BIP program has a huge impact for states,
especially for states who have MFP and the waiver.
You got all these waiver authorities, you got MFP, and you got BIP,
you got all these grant programs and how they work together
and [inaudible] services is a huge is a huge for states but it's certainly a win-win
for those states who do have all three.
>> Thank you so much for that.
Colleen, I had a -- we had a couple of follow-up questions pertaining
to how the coworker idea could be infused into a waiver or could be paid for.
The first is whether or not coworker structure could be used to get funding
to a current employee at a job to aid an individual, or a colleague with a disability,
or would -- or could it be used to fund an additional staff person
to work alongside the individual?
>> Yes. Well, the purpose would be to fund a coworker, a current employee at the job
to support the individual and it can be paid for with waiver funds.
So, for example if the state gives Provider A $10 an hour for job coaching,
the provider could then subcontract with that coworker through a subcontracting arrangement
and pay that coworker a dollar or $2 extra an hour in addition to those salaries
that they're getting from the employer to provide the coworker supports.
>> That's really helpful.
Thank you.
The other thing - the other question about this is whether --
it says, "Are you aware of any states paying a coworker as a natural support,
or using the peer worker support model?"
I think you spoke a little bit about peer supports, but can you speak a little bit
to the first part of this question about paying a coworker the natural support?
>> Well, let me just say that the way I view it, and this is just Colleen's world,
I see a very large distinction between a natural support and a paid coworker support.
A natural support is not paid.
It's a coworker that as a goodness of their heart has offered to provide some supports
to the individual, you know, to get them through their day.
That's a natural support.
A coworker -- paid coworker support is where you're actually paying a coworker
and they acknowledge that they're receiving payment for the purpose of providing
that same service to the individual.
So, I see a distinction there.
That's the way I -- my little world sees it.
>> That's a great clarification and way to describe the two distinct phenomenon.
So, thanks for sharing that.
I think we just have a -- one or two more questions before we wrap up.
One question that we received today prior to the presentation
and that I know is a question you get a lot, which is around time limits,
and as you so eloquently described in your presentation, CMS was very clear
in its informational bulletin that prevocational services should be time-limited but really
that did not put in motion a set time or a --
or establish an actual quantifying criteria in that first state.
Merely, left it up to the states.
I was curious and pleased to hear you also mentioning your presentation that CMS, you know,
also used group support and employment services not as a long-term endpoint,
but as a transition [inaudible] you know you go and you get some training experience
and you hopefully move on to other things.
So, my question for you is for states that are trying --
that are in the process of trying to figure out either phase progression of activities,
or time limits that they want to put into place for these services,
are there any specific criteria or standards that --
or things that you'll be evaluating applications that come in based on --
just to give states somewhat of a sense of that the types of factors you'll be looking
at to determine whether or not the time limits that they're proposing are consistent
with the spirit of the informational bulletin.
>> Well, for example, I had -- we had a state that came
in with a five-year time period for prevocational services.
And so, you know, my response to that proposal was why does it take you five years
to find an individual a job?
You know, if the individual says they want a job, then you need to sure up your resources
so that individuals can have a job.
And I'm not saying that that's easy, believe me, I've been there and I've done it.
I've worked for a provider agency that closes down a sheltered workshop.
So, I do understand the intricacies in doing that.
It's not easy.
But, five years is a little out of the ballpark, I think.
I don't think that's realistic.
There are some states that have come in with 12 months, some that have come in with 24 months,
some that came in with, I think, Maryland if I'm not mistaken is six months.
I should know, I wrote it, but it's been that long ago that I wrote it
that I can't remember, but I think it was six months.
The bottom line is that, it should be a short-term gearing-up period for the individual
where they're learning some intense employment skills so that they can go
out and get a job in the real world.
And not that they, again, linger on forever in the day.
So, I guess, one of the things that we'll be looking at is,
what is the time frame and is it realistic?
Two years, maybe that's stretched and maybe that might be acceptable,
but if there is an individual who says they want a job and they are ready
to work, ready to roll, you know.
Maybe they're just out of high school and they say they want to work,
then the goal for that individual should be work.
It should not be prevocational services.
You have to meet the person where they are.
>> [Multiple speakers].
>> That's really very, very helpful.
Our time is up.
I really cannot thank the two of you enough for your time.
I know -- actually, I can't even fathom how busy you
and your respective teams are at CMS these days.
So, it means a lot to us that you made yourselves available for this national dialogue.
I think I'm hoping that folks on the phone got as much out of it as we did.
I know that we get so many questions related to all of the exciting policy developments coming
out of CMS on a regular basis that we thought it was absolutely essential to host these sessions.
So, I thank you both very much for your time and expertise today.
It was just really incredible.
I want to encourage folks that are on the phone today, if you have not already registered
or signed up for the second webinar, which will be hosted the same time next Thursday,
a week from today, from 2 to 4 p.m. Eastern time, please do so as soon as possible.
There's limited space available and please submit your questions.
The topic of that webinar is going to be focused on the final HCBS rule
and some general information around that, so please submit your questions.
As Colleen said, she'll be back with her boss, Ralph Lollar,
the Division of Long Term Supports -- Services and Supports.
And until then, I hope everyone has a great week and thank you again so much,
Colleen and Jeffrey, your time today.
It was really exceptional.
Greatly appreciated.
>> Thank you.
Our pleasure.
>> Thank you, everybody.
>> Thank you.
Take care.