providing and coordinating financial management & supports brokerage

www.PublicPartnerships.com148 State Street, 10th Floor, Boston, MA 02109, 617 426 2026 main 617 426 4632 fax

Providing and Coordinating Financial Providing and Coordinating Financial Management & Supports BrokerageManagement & Supports Brokerage

US DHHS/OASPE Sponsored Government and Vendor Fiscal/Employer Agent US DHHS/OASPE Sponsored Government and Vendor Fiscal/Employer Agent WorkshopWorkshop

November 2, 2007, Baltimore, MDNovember 2, 2007, Baltimore, MD

Public Partnerships, LLC

Client

Welcome & IntroductionsWelcome & Introductions

Sandy Barrett, Cash & Counseling National Program Office

David Horvath, Public Partnerships, LLC

Marise McFadden, New Mexico Aging and Long Term Services Division – Mi Via Program

Bill Ditto, New Jersey Division of Disability Services – Personal Preference Program


Client

Session OverviewSession Overview

Basic Design Considerations

Supports for Participant Direction

Models of Financial Management and Supports Brokerage

Combined F/EA and SB: West Virginia Personal Options

Separate F/EA and SB: New Mexico Mi Via

Moving from Multiple to Single Vendor: New Jersey Personal Preference

Audience Discussion


Client

Participant-Directed Service Participant-Directed Service ModelsModels

Basic Design ConsiderationsBasic Design Considerations

1. What opportunities will be available for participant direction?

2. How will the state provide and pay for supports for participant direction?

- Financial Management Services- Information and Assistance in Support of Participant Direction

1. How will the state (and providers or vendors) ensure communication, cooperation, coordination, and collaboration?


Client

Opportunities for Participant Direction Opportunities for Participant Direction

(Employer Authority, Budget Authority, (Employer Authority, Budget Authority, Both)Both)

Budget Authority

Participant has authority and responsibility to manage budget

Varying levels of budget authority

Employer Authority (Hallmark of The RWJF Cash & Counseling model)

Participant is supported to recruit, hire, supervise and direct workers

Participant functions as common law employer or co-employer

Required for Independence Plus designation

Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers,

Centers for Medicare & Medicaid Services


Client

Supports for Participant Direction Supports for Participant Direction Required by CMSRequired by CMS

Financial Management Services and

Information and Assistance in Support of Participant Direction

Purposes and Functions

Types of Entities

Payment Authorities

Core Service Definitions

Guidance to States


Client

Financial Management ServicesFinancial Management ServicesPurposesPurposes

(a) To address Federal, state and local employment tax, labor, and worker’s compensation insurance rules and other requirements that apply when participant functions as the employer of workers and

(b) To make financial transactions on behalf of the participant when the participant has budget authority




Client

Financial Management ServicesFinancial Management ServicesTypesTypes

1. Fiscal/Employer Agent (Government or Vendor)

where the entity is the agent to the common law employer who is either the participant or his or her representative or

2. Agency with Choice

where the participant and the agency function as co-employers of the participant’s worker(s).




Client

Financial Management ServicesFinancial Management ServicesBasic FunctionsBasic Functions

Assistance with Budget Authority

Act as a neutral bank, receiving and disbursing public funds, tracking and reporting on the participant’s budget (funds received, disbursed, and any balances (F/EA FMS)

Process and pay invoices for goods and services in the participant’s approved service plan (F/EA FMS) and,

Prepare and distribute reports (e.g., budget status and expenditure reports) to participants and other entities specified in the waiver (FEA and Agency with Choice FMS)




Client

Financial Management ServicesFinancial Management ServicesBasic FunctionsBasic Functions

Assistance with Employer Authority Assist the participant in verifying worker’s citizenship or legal alien

status (e.g., completing and maintaining a copy of the BCIS Form I-9 for each support service worker the participant employs) (F/EA and Agency with Choice FMS)

Collect and process support worker’s timesheets (F/EA and Agency with Choice FMS) and,

Operate a payroll service, (including withholding taxes from worker’s pay, filing and paying Federal (e.g., income tax withholding, FICA and FUTA), state (e.g., income tax withholding and SUTA, and when applicable, local employment taxes and insurance premiums); and distribute payroll checks on the participant’s behalf (F/EA and Agency with Choice FMS).




Client

Financial Management ServicesFinancial Management ServicesAdditional FunctionsAdditional Functions

When specified in the waiver, an FMS entity may perform additional functions, including:

Executing provider agreements on behalf of the Medicaid agency or

Brokering and paying worker’s compensation or other types of insurance premiums on behalf of participants.

The nature and scope of FMS hinges on the participant direction opportunities that are available under the waiver.




Client

Financial Management ServicesFinancial Management ServicesPayment Authority OptionsPayment Authority Options

Waiver Service Rate: State’s Federal Medical Assistance

Percentage (FMAP) rate

FMS Entities: Any provider that meets qualifications specified in Appendix C-3

Participant Selection: Free choice of any qualified FMS provider

Contractual Relationship: Medicaid provider agreement between FMS entity and the state

OHCDS: FMS entity may function as an OHCDS by virtue of providing a waiver service (FMS)

Administrative Activity Rate: Administrative FFP rate (50%)

FMS Entities: Administrative procurement (e.g., RFP) – The number and type of FMS entities may be limited.

Participant Selection: Limited to the FMS entities contracted by the state

Contractual Relationship: Contract between FMS entity and State

OHCDS: FMS entity may not function as an OHCDS


Client

Information and Assistance in Support Information and Assistance in Support of Participant Directionof Participant Direction

Purpose and FunctionsPurpose and Functions

These supports are made available to participants to help them manage their waiver services.

- For example, assistance might be provided to help the participant locate workers who furnish direct supports or in crafting the service plan.

The type and extent of the supports that must be available to participants depends on the nature of the participant direction opportunities provided under the waiver.




Client


Core Service DefinitionCore Service Definition

Service/function that assists the participant (or the participant’s family or representative, as appropriate) in arranging for, directing and managing services.

Serving as the agent of the participant or family, the service is available to assist in identifying immediate and long-term needs, developing options to meet those needs and accessing identified supports and services.

Practical skills training is offered to enable families and participants to independently direct and manage waiver services. Examples of skills training include providing information on recruiting and hiring personal care workers, managing workers and providing information on effective communication and problem-solving.




Client


Core Service DefinitionCore Service Definition: : (continued)(continued)

The service/function includes providing information to ensure that participants understand the responsibilities involved with directing their services.

The extent of the assistance furnished to the participant or family is specified in the service plan.

This service does not duplicate other waiver services, including case management.




Client


CMS Guidance to StatesCMS Guidance to States

Information may be provided to participant about: Person-centered planning and how it is applied;

Range and scope of individual choices and options;

Process for changing the plan of care and individual budget;

Grievance process;

Risks and responsibilities of self-direction;

Freedom of choice of providers;

Individual rights;

Reassessment and review schedules; and,

Such other subjects pertinent to the participant and/or family in managing and directing services.




Client

Information and Assistance in Support Information and Assistance in Support of Participant Direction of Participant Direction

CMS Guidance to StatesCMS Guidance to States

Assistance may be provided to the participant with: Defining goals, needs and preferences, identifying and accessing services,

supports and resources;

Practical skills training (e.g., hiring, managing and terminating workers, problem solving, conflict resolution)

Development of risk management agreements;

Development of an emergency back up plan;

Recognizing and reporting critical events;

Independent advocacy, to assist in filing grievances and complaints when necessary; and,

Other areas related to managing services and supports.




Client

Information and Assistance in Support of Information and Assistance in Support of Participant DirectionParticipant Direction

Payment Authority OptionsPayment Authority Options

1. Case Management Activity - Waiver Service (Case Management) (FMAP Rate)- State Plan Service (Targeted Case Management)- Administrative Activity (Medicaid Personnel or Contracted) (FFP rate %50)

2. Waiver Service Coverage (FMAP Rate)- One or more distinct waiver services (Supports Broker or Personal Agent)- May be furnished as part of Financial Management Services- State must enroll all qualified providers- Participant has free choice of all qualified providers- May not require participants to receive SB and FMS from same provider

3. Administrative Activity (FFP Rate %50)- Furnished by Medicaid agency personnel or contracted entities- Considerations similar to payment authority for FMS

Note: May combine payment authorities




Client

West Virginia West Virginia Personal OptionsPersonal OptionsOverviewOverview

1915(c) Waiver

Approximately 5,000 Adults with Physical Disabilities and Seniors

Nursing Facility Level of Care

Monthly Budget Based on Level of Care (A,B,C,D)

Waiver Amendment Added Participant Direction

Budget Authority and Employer Authority

Approximately 120 Enrolled Since May, 2007


Client

West Virginia West Virginia Personal OptionsPersonal OptionsOpportunities for Participant DirectionOpportunities for Participant Direction

Budget Authority

Homemaker Services (within LOC)

Homemaker RN Services

Case Management Services

Homemaker Transportation Services

Participant-Directed Goods and Services (Up to $1,000 annually)

Employer Authority

Homemaker Services


Client

West Virginia West Virginia Personal OptionsPersonal OptionsCombined F/EA and SB ModelCombined F/EA and SB Model

Single Vendor (Public Partnerships, LLC)

Financial Management Services- Fiscal/Employer Agent (F/EA FMS)

Information and Assistance in Support of Participant Direction- Supports Broker (Resource Consultant)- Participant may also purchase case management

Administrative Payment Authority (FMAP %50)- Blended Rate for F/EA and SB Services- Indexed to Level of Care- Not based on units of service


Client

Combined F/EA and SB ModelCombined F/EA and SB ModelAdvantagesAdvantages

1. Maximum administrative control

2. Ease of vendor selection (RFP Process)

3. Promotes communication (Single point of contact for state; One-stop service delivery for participant)

4. Promotes collaboration (F/EA and SB are same)

5. Operational efficiencies (Reduced meetings, shared systems, etc.)

6. Promotes economies of scale

7. Training efficiencies

8. Ease of monitoring single vendor


Client

Combined F/EA and SB ModelCombined F/EA and SB ModelChallengesChallenges

1. Limits participant choice

2. Match rate limited to 50%

3. Possible concerns re: service steering

4. Limits competition

5. Potential conflict of interest (If supports broker assesses level of service and financial management rate is tied to level of service)


Client

Separate F/EA and SB ModelSeparate F/EA and SB ModelAdvantagesAdvantages

1. Maximizes participant choice (Ultimate is personal agent or independent support broker model; 1 to 1)

2. Opportunity for higher match rate

3. Competition among vendors may improve quality


Client

Separate F/EA and SB ModelSeparate F/EA and SB ModelChallengesChallenges

1. Costs associated with training, certifying, recertifying and monitoring multiple vendors or providers

2. Difficulty ensuring communication, cooperation, coordination, and collaboration between and among multiple vendors or providers

3. Difficult to achieve economies of scale

4. Difficult to attract vendors or providers to small market segment(s)

providing and coordinating financial management & supports brokerage

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