Funding Iowa’s Services for the Chronically Mentally Ill

Medicaid Mental Health Services in Iowa • Traditional clinical services – Diagnosis, treatment, therapy, etc. provided through Managed Care contractor since 1995 – This remains unchanged • Supportive Services in the Community – In-home services, vocational, etc. – For adults, most are no longer are state plan rehabilitation services; now are state plan Home and Community Based (HCBS) services

The Old Model Two programs operating under Medicaid State Plan rehabilitation section : • Rehabilitative Treatment and Support Services - CW system children • Adult Rehabilitation Option (ARO) – Adults with Chronic Mental Illness – Federal OIG audits – many services not rehabilitative; payback of federal dollars – Increased federal scrutiny; expected tightening of regulations – Decision to discontinue both programs and redesign.

The New Model • Separation of rehabilitative and non- rehabilitative services: – “Remedial Services” – Rehabilitative; still under state plan rehab section – “HCBS Habilitation Services” – Can be non-rehabilitative; State Plan benefit authorized under Section 6086 of DRA 2005

The New Model • Remedial Services – Delinked from CW system; no age restrictions – Medical model • LPHA directs services: clinical assessment and diagnosis, completes treatment plan, reviews progress every 6 months • Remedial Service Providers (RSPs) develop service plan based on the LPHA’s treatment plan • Rehabilitative, skill-building services • Service plan authorized by IME Medical Services • RSP provides service and documents

HCBS Habilitation Services State Plan Option • Section 6086 of DRA 2005 • Effective January 1, 2007, states can amend their Medicaid State Plan to offer Home and Community Based Services (HCBS) as a state plan optional benefit. • Is HCBS, but is not a waiver.

Services Services designed to assist in acquiring, retaining and improving the self-help, socialization and adaptive skills necessary to reside successfully in home and community- based settings. • Case Management • Habilitation – Day Habilitation – Home-Based Habilitation – Prevocational Habilitation – Supported Employment Habilitation

Services Case Management • Assists members in gaining access to needed home- and community-based habilitation services, as well as medical, social, educational, and other services, regardless of the funding source • Same functions as Targeted Case Management • Service coordination for persons not eligible for regular TCM

Services • Home-Based Habilitation – Services provided in the person’s home and community. Typical examples would be assistance with medication management, budgeting, grocery shopping, personal hygiene skills, etc. • Day Habilitation - provided in a day program setting outside the home. Focuses on areas such as social skills, communication skills, behavior management, etc.

Services • Prevocational – Can be provided in a variety of settings, and focuses on developing generalized skills that prepare a person for employment. Typical examples include attendance, safety skills, following directions, and staying on task. • Supported Employment – Assists in obtaining and keeping a job in the community. Assists in placing the individual in a job in a regular work setting with persons without disabilities at minimum wage or higher, and provides support to maintain the job. Typical examples would include: skills assessments, consultation with the employer, job coaching, and behavior management.

HCBS State Plan Services Advantages to the State •No distinction between rehabilitative vs. non-rehabilitative services •No requirement for institutional level of care •No periodic federal renewal •No requirement to demonstrate cost- neutrality •Can limit enrollment (slots) •Flexibility in how services are defined

HCBS State Plan Services Disadvantages to the State • Only one benefit per state. • Financial Eligibility - more restrictive than waivers - Income must be below 150% of Federal Poverty Level • No Waiver of Comparability – cannot target the program by population characteristics – “Needs based” - must use functional criteria – Functional criteria for Iowa are based on our existing definition of “chronic mental illness”.

HCBS State Plan Services Other Requirements and Options for the State •Quality Assurance/Technical Assistance •Self-Direction (optional) •Can waive statewideness

Implementation Issues •What went well –Communication with CMS regional office throughout process –Stakeholder involvement •What didn’t: –Provider rate setting

More Information Habilitation Services website: http://www.ime.state.ia.us/HCBS/HabilitationServices/Info.html Contact Information: Don Gookin Iowa Medicaid Enterprise (515) 725-1141 dgookin@dhs.state.ia.us

Supplementary Information

Iowa’s Needs Based Eligibility Criteria • Meets 1 of 2 risk factors: – Has undergone or is currently undergoing psychiatric treatment more intensive than outpatient care, more than once in a lifetime (e.g., emergency services, alternative home care, partial hospitalization or inpatient hospitalization). – Has a history of psychiatric illness resulting in at least one episode of continuous, professional supportive care other than hospitalization. (e.g., residential placement)

Needs Based Eligibility Criteria (cont’d.) • Meets at least 2 of 5 criteria showing a need for assistance for at least two years: – Is unemployed, or employed in a sheltered setting, or have markedly limited skills and a poor work history. – Requires financial assistance for out-of-hospital maintenance and may be unable to procure this assistance without help. – Shows severe inability to establish or maintain a personal social support system. – Requires help in basic living skills such as self-care, money management, housekeeping, cooking, or medication management. – Exhibits inappropriate social behavior that results in demand for intervention.

HCBS Habilitation Services Similarities Between HCBS Waivers and HCBS State Plan • Directed by case managers • Assessment of need for services by case manager • Evaluation to determine program eligibility • Individualized, person-centered plan of care by Interdisciplinary team • State can limit enrollment (slots) • Authorization through ISIS • Quality Assurance/Quality Improvement

HCBS Habilitation Services Process • Similar process as used by Iowa’s current HCBS waiver programs. • Functional abilities assessment by case manager • Determination of eligibility by IME Medical Services (Iowa Foundation for Medical Care) • Comprehensive service plan developed by case manager and interdisciplinary team • Case manager enters services into ISIS system • Service plan is authorized by IME Medical Services • Services are provided and documented • Annual update of assessments and service plans

Services Case Management • Assists members in gaining access to needed home- and community-based habilitation services, as well as medical, social, educational, and other services, regardless of the funding source • Same requirements as Targeted Case Management • NOTE: can only be provided as a Habilitation service for persons not eligible for regular TCM

Services Day Habilitation •Assistance with acquisition, retention, or improvement in self-help, socialization, and adaptive skills. •Activities and environments designed to foster the acquisition of skills, appropriate behavior, greater independence, and personal choice. •Services focus on enabling the member to attain or maintain the member’s maximum functional level.

Services Day Habilitation Services must enhance or support the member’s: Intellectual functioning.  Physical and emotional health and development.  Language and communication development.  Cognitive functioning.  Socialization and community integration.  Functional skill development.  Behavior management.  Responsibility and self-direction.  Daily living activities.  Self advocacy skills.  Mobility. 

Services Day Habilitation • Day Habilitation cannot be provided in the member’s residence. • If the member lives in a residential facility of more than 16 persons, Day Habilitation can be provided in an area of the facility that is apart from the member’s sleeping accommodations, such as a common room where residents normally congregate.

Services Home Based Habilitation • Individualized services and supports that assist with the acquisition, retention, or improvement in skills related to living in the community. • Provided in the member’s home or community and assist the member to reside in the most integrated setting appropriate to the member’s needs. • Provide for the daily living needs of the member • Can be provided at any time of day or night that is necessary to meet the member’s needs.

Services Home Based Habilitation Includes the following supports: • Adaptive skill development. • Assistance with activities of daily living. • Community inclusion. • Transportation (except to and from a day program). • Adult educational supports. • Social and leisure skill development. • Personal care. • Protective oversight and supervision.

Services Home Based Habilitation • Transportation is acceptable if it supports the acquisition, retention, or improvement of another skill, such as grocery shopping, getting medical care, etc. • Personal care and Protective oversight and supervision may be a component, but may not comprise the entirety of the service. • Home-based habilitation cannot be provided to members who reside in a residential facility of more than 16 beds. • Even when Home-Based Habilitation is provided using a daily rate, it does not include room and board or maintenance costs.

Services Prevocational Habilitation • Designed to prepare a member for paid or unpaid employment. • Does not include training to do any specific job or task, but instead is aimed at a generalized result that can be used in any employment setting. • Teaching concepts such as compliance, attendance, task completion, problem solving, and safety. • Variety of settings (member’s home, community, sheltered workshop) depending on the needs of the member.

Services Prevocational Habilitation • In a workshop setting, only reimbursable service is the generalized skills training – supervision or task-work alone is not payable • Payments to the consumer cannot be made from Medicaid funds • Designed as a limited time service

Services Supported Employment • Designed to assist members in obtaining and maintaining competitive paid employment • Intensive, ongoing supports that enable members to perform in a regular work setting • Provided to members who need support because of their disabilities and who are unlikely to obtain competitive employment at or above the minimum wage

Services Supported Employment Activities to Obtain a Job: • Initial vocational and educational assessment to develop interventions that affect the member’s work. • Job development. • On–site vocational assessment before employment. • Disability–related support for vocational training or paid internships. • Assistance in helping the member learn the skills necessary for job retention, including skills to arrange and use transportation, and for job exploration.

Services Supported Employment Supports to Maintain Employment: • Individual work–related behavioral management. • Job coaching. • On–the–job or work–related crisis intervention. • Assistance in the use of skills related to sustaining competitive paid employment, including communication skills, problem solving, and safety. • Assistance with time management. • Assistance with appropriate grooming. • Employment–related supportive contacts. • On–site vocational assessment after employment. • Employer consultation.

Services Supported Employment • Variety of community based settings where people without disabilities work (majority of co-workers are people without disabilities; daily contact with co- workers or public without disabilities if that is typical for the job) • Enclave setting of no more than 8 consumers. • Community transportation must be attempted before provider transportation.

Funding Iowa’s Services for the Chronically Mentally Ill

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