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  • In the early 1990s, local disability advocacy groups publicized the need to allow workers with disabilities to retain their MA eligibility. The 1995 Minnesota Legislature authorized the Department of Human Services to seek a waiver from the federal government that would establish an earned income benefit for employed people with disabilities eligible for Social Security Disability Insurance and receiving personal care services under MA. In 1998, the Minnesota Legislature asked Congress to remove Medicaid policy barriers to the employment of people with disabilities and in May 1999, the Minnesota Legislature approved MA-EPD. MA-EPD was implemented on July 1, 1999. Enrollment in the program grew rapidly and exceeded expectations.
  • Very high enrollment trends from 9-99 to 1-01, part of this was pent up demand, there had been advocacy effort since the early 90’s – people knew about the program and wanted on. 9-04 was the biggest decline, and this coincided with our changes to make the program more of a work incentive, ending no taxes needed to be withheld for DTH enrollees, and $1 and your on. Have had a gradual very slow increase since that time. No effect in MN from Part D.
  • The first question that we in MN get every time anyone wants to ask about our buy-in is, “how can you not have a cap on income? The policies of our program fit with MN.
  • There has never been an income limit. I can’t wait to have to bring the best policy people in the state together to sort out what we are going to do because enrollees are earning too much money!
  • In MN, for standard MA, people with incomes (based on household size) above 100% FPG have to spend down to 75% FPG. Someone with a household size of one, with income one dollar over 100%, or $852/month, would have to spend down to $639/month. They would have a $212 spend down each month vs. a $35 MA-EPD premium.
  • Manual Billing System: Because the cost-sharing element of MA-EPD is different than most other public programs, MA-EPD has its own premium billing and collection system, outside of the regular Medicaid management system. The MA-EPD billing system is manually driven and completely dependent on correct and timely notification and data entry on the part of county financial workers, tribal workers and DHS billing staff. This results in it being prone to errors. Lack of clear definition of “work”: The Ticket to Work and Work Incentives Improvement Act, which authorizes the Medicaid Buy-In program for MN, does not allow states to define “work.” States struggle with this issue. In 2003, legislation was adopted in MN requiring Medicare and Social Security taxes to be paid or withheld from earnings to qualify as employment for MA-EPD. Still, the number one question from consumers and those determining program eligibility remains, “Does this qualify as work?” It would be very helpful if states could define employment for their Medicaid Buy-In programs. SSDI Cash Cliff: While there is no upper income limit for MA-EPD, there still exists an upper income limit for other public programs such as SSDI. The vast majority (95%) of MA-EPD enrollees also receive SSDI. MA-EPD enrollee earnings data shows that enrollees on SSDI earn less than those not on SSDI. One reason for this may be the fear of losing SSDI benefits. Earnings would likely increase if there was a earnings ramp, where SSDI benefits decreased gradually as earnings increased, instead of completely stopping at the SGA level.
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  • It is an honor to appear before you today to discuss Alabama’s Personal Choices program and how expanding consumer-directed care fits into our state’s plan to transform Medicaid and improve health outcomes. The Alabama Medicaid Agency has a long-standing commitment to community-based care. Our two largest home and community-based waiver programs have been in existence since the early 1980s, and today, more than 14,000 Alabama residents currently choose to participate in one of six programs as an alternative to institutional-based care. More recently, the state of Alabama has made a commitment to Medicaid transformation. As a result, Alabama was awarded a 7.6-million-dollar grant in January of 2007 for “Together for Quality,” an initiative that will create a statewide electronic health information system while establishing a comprehensive, quality improvement model for the Alabama Medicaid program. The Personal Choices program is an important step in this journey away from a process-oriented program to one that is patient-focused, quality-oriented and cost-efficient.
  • Our original plan was to submit Personal Choices as an 1115 Research and Demonstration waiver. The Centers for Medicare and Medicaid Services (CMS) asked us instead to take advantage of the new provisions of the DRA and submit it as a State Plan Amendment. We submitted our request to amend Alabama’s State Plan in December of 2006 and received approval in May 2007.
  • The new DRA provision that made this possible is Section 6087, or 1915(j) . This provision allows states to implement programs which incorporate self-directed care. One unique aspect of this provision is that it allows states to target specific populations. In Alabama, this meant we could implement the Personal Choices program in a way that ensured the health and safety of our recipients as well as overall program success.
  • We believe the Personal Choices program represents real value to taxpayers and to our recipients. It allows us to live within our budget because no additional expense is projected. At the same time, it offers the potential for multiple consumer benefits.
  • For those recipients who want to exercise greater control over their daily lives, Personal Choices potentially offers improvements in terms of consumer satisfaction, reducing caregiver stress, increasing access to services and positive health and safety outcomes. Changing caregivers or making new care arrangements is a risk our vulnerable clients do not undertake casually. This program based on a State Plan Amendment assures recipients that our commitment to this effort is for the long-term.
  • For Alabama, offering this program under a State Plan Amendment frees us to focus on nurturing and supporting the program while removing the workload and expense associated with periodic waiver renewals. Research from other states suggests that the state will benefit in other ways as well, most notably in terms of cost reduction and quality improvements.
  • Personal Choices is a program in which we have great confidence. The model on which it is based is popularly known as the “Cash and Counseling Model” which has been extensively tested in conjunction with the Robert Wood Johnson Foundation and CMS. We will closely monitor this effort to ensure that patient safety and overall service meets or exceeds what the current program now offers.
  • The Personal Choices program is scheduled to start on August 1st in seven west Alabama counties, including some of the nation’s most impoverished areas. Nearly 700 individuals can choose to participate in this voluntary program which is limited to personal care or personal assistance services.
  • The Alabama Medicaid Agency will work in partnership with two other state agencies to implement this program. The Alabama Department of Senior Services will administer the program in tandem with the Alabama Department of Rehabilitation Services. Both agencies are already actively involved with recipients who are eligible for this program.
  • To participate in “Personal Choices,” eligible individuals must be in a qualifying waiver program for the elderly or disabled, live in one of the seven pilot counties, accept the responsibility for working with a counselor to develop and follow a spending plan, hire and manage support workers, and follow the budget based on assessed need. NOTES: Counties:
  • Changing to consumer-directed care requires that the state take extra measures to ensure services that are provided are appropriate. Alabama has built safeguards into its program that include use of a qualified fiscal Employer Agent and counselors to assist clients. Additionally, Counselors will work with recipients to provide clear definition and communication about program parameters, including what can and cannot be purchased. Counselors will also be responsible for closely reviewing budget plans and for reviewing worker time sheets and check requests.
  • As we prepare to launch the Personal Choices program in Alabama, we are energized by the possibilities that lie ahead for our state. It is our hope that the Personal Choices program is but one of many quality improvement projects that will allow us to move away from our traditional, process-oriented system to one that is coordinated, patient-centered and cost-efficient.
  • state presentations

    1. 1. Minnesota’s Medicaid Buy-In Medical Assistance for Employed Persons with Disabilities (MA-EPD)
    2. 2. <ul><li>The goal of the program is to encourage people with disabilities to work and enjoy the benefits of being employed, and </li></ul><ul><li>Promote competitive employment and the economic self-sufficiency of people with disabilities </li></ul>MA-EPD Goals Medical Assistance for Employed Persons with Disabilities
    3. 3. Background <ul><li>Grassroots effort by advocacy groups led to Minnesota legislature’s adoption of Medicaid Buy-In program </li></ul><ul><li>Efforts began in the early ’90s to demonstrate the need for allowing workers with disabilities to retain their Medicaid eligibility </li></ul>Medical Assistance for Employed Persons with Disabilities
    4. 4. <ul><li>“ It’s a great program. I don’t </li></ul><ul><li>know what I would do without it.” </li></ul><ul><li>Bill </li></ul><ul><li>“ I want to make sure my premium is there on time. I don’t want to lose this great coverage.” </li></ul><ul><li> Kathy </li></ul>Medical Assistance for Employed Persons with Disabilities
    5. 5. General Enrollment Data Data Source: MMIS Medical Assistance for Employed Persons with Disabilities
    6. 6. Changes in MA-EPD Policy Medical Assistance for Employed Persons with Disabilities <ul><li>To be considered employment, Social Security and Medicare taxes must be withheld </li></ul><ul><li>Effective 1/01/04 </li></ul><ul><li>Certain employers are exempt from withholding taxes (sheltered workshops and day activity centers) </li></ul><ul><li>Effective 11/01/01 </li></ul>TAX WITHHOLDING <ul><li>$35 minimum premium payment for all enrollees using current premium structure </li></ul><ul><li>Effective 1/01/04 </li></ul><ul><li>Premium payment for individuals whose combined total monthly gross income meets or exceeds 100% FPG. Payments begin at $7/month. </li></ul><ul><li>Effective 11/01/01 </li></ul>PREMIUM PAYMENT <ul><li>$65 earned income disregard </li></ul><ul><li>(More than $65 total gross monthly earned income to be eligible) </li></ul><ul><li>Effective 1/01/04 </li></ul><ul><li>Total gross monthly earned income of $1.00 or higher to qualify </li></ul><ul><li>(No earned income requirements) </li></ul>EARNED INCOME WORK INCENTIVE POLICY EARLY MA-EPD POLICY
    7. 7. “ There really is a program that doesn’t make you be poor before you can use it? Wow!” Nancy Medical Assistance for Employed Persons with Disabilities
    8. 8. Changes in MA-EPD Policy <ul><li>Four-month continuation of eligibility due to job loss for reasons other than conduct </li></ul><ul><li>Effective 1/01/04 </li></ul><ul><li>Not applicable </li></ul>4-MONTH ELIGIBILIY (JOB LOSS) <ul><li>Four-month continuation of eligibility due to medical reasons </li></ul><ul><li>Effective 11/01/01 </li></ul><ul><li>Two-month continuation of eligibility due to medical reasons </li></ul><ul><li>Effective 11/01/00 </li></ul>4-MONTH ELIGIBILIY (MEDICAL) <ul><li>Enrollees must pay one-half of one percent of total monthly unearned income </li></ul><ul><li>Effective 11/01/03 </li></ul><ul><li>No additional fee tied to unearned income </li></ul>UNEARNED INCOME <ul><li>Medicare Part B premiums reimbursed only if enrollee is not eligible for QMB/SLMB and has total income at or below 200% FPG </li></ul><ul><li>Effective 11/01/03 </li></ul><ul><li>All Medicare Part B premiums reimbursed using State funds for enrollees not QMB/SLMB eligible (county reimburses enrollee, state reimburses county </li></ul>MEDICARE PART B Medical Assistance for Employed Persons with Disabilities WORK INCENTIVE POLICY EARLY MA-EPD POLICY
    9. 9. With today’s economy and job market, we’ve seen many people lose their jobs, through no fault of their own. Like Ed, who is a software developer. Ed had worked for the company for 13 years when he was laid off due to down-sizing. Without the 4-month job loss leave he would have been without medical coverage. He was able to find another job before his 4 months expired and had continuous medical coverage. MA-EPD Safety Net Medical Assistance for Employed Persons with Disabilities
    10. 10. Compare: MA and MA-EPD Medical Assistance for Employed Persons with Disabilities First $65 Sliding fee scale premium based on income and household size. Minimum of $35. Unearned income obligation (½% of gross unearned income) Must be employed or self-employed, earning more than $65 (average) monthly, and Medicare and Social Security taxes paid or withheld $20,000 per individual; also excludes spouse’s assets, retirement accounts, and medical expense accounts set up by an employer No upper income limit Medical Assistance for Employed Persons with Disabilities (MA-EPD) First $65 ½ of remaining MA with spend down (if above $851 single, must spend down to 75% FPG = $639 single) None $ 3000 single $ 6000 couple 100% FPG $851 single $1141 couple Medical Assistance (MA) Earned Income Disregards Cost Sharing Work Requirement Asset Guidelines Income guidelines Name of Program
    11. 11. “ I could work more but I make sure I don’t work more than 18 hours each week so I don’t lose my SSDI.” Doug Medical Assistance for Employed Persons with Disabilities
    12. 12. <ul><li>Manual Billing System </li></ul><ul><li>Lack of clear definition of “work” </li></ul><ul><li>SSDI Cash Cliff </li></ul>Challenges Medical Assistance for Employed Persons with Disabilities
    13. 13. “ I started working to get on MA-EPD but now I’m working because I like it. It gives me something to do and I work with some really fun people.” Laura Medical Assistance for Employed Persons with Disabilities
    14. 14. Stay Well, Stay Working Benefit Package Health Care Services (modeled on Medicaid State Plan) – Medica / UBH Wellness Employment Navigator Services – MN Resource Center Employee Assistance Program – Optum Intensive Employment Assistance Services as needed – MN Resource Center Peer-Facilitated WRAP Services – Consumer Survivor Network
    15. 15. <ul><li>Employment stability & job performance </li></ul><ul><li>Health management </li></ul><ul><li>Quality of life </li></ul><ul><li>Frequency of symptoms of mental illness </li></ul><ul><li>Access to employer-sponsored health benefits </li></ul><ul><li>Benefits of person-centered supports </li></ul><ul><li>How employees access support services </li></ul>Stay Well, Stay Working Outcomes to be Studied
    16. 16. For further information contact: Beth Grube, Policy Consultant [email_address] 651- 431-2412 Or MaryAlice Mowry, Director, Pathways to Employment & Stay Well, Stay Working [email_address] 651- 431-2384 Medical Assistance for Employed Persons with Disabilities
    17. 17. WORK ( Work Opportunities Reward Kansans ) Mary Ellen O’Brien Wright Kansas Health Policy Authority
    18. 18. Work Opportunities Reward Kansans WORK <ul><li>Approved under the Deficit Reduction Act – State Flexibility in Benefit Packages (Section 6044) </li></ul><ul><li>A Secretary Approved Benchmark Benefit package </li></ul><ul><li>A “package” of benefits designed for adults with disabilities who are employed and enrolled in the Kansas Medicaid Buy-In program, Working Healthy </li></ul>
    19. 19. “ Cash and Counseling” Model <ul><li>Goes a step beyond consumer self-direction </li></ul><ul><li>Allows consumers to directly manage their funds </li></ul><ul><li>Offers flexibility in terms of what services are purchased, and how they are purchased </li></ul>
    20. 20. Working Healthy Eligibility <ul><li>Two Optional Medicaid Categories: “Basic” and “Medically Improved” </li></ul><ul><li>Federal Requirements </li></ul><ul><ul><li>16-64 years of age </li></ul></ul><ul><ul><li>Determined disabled by SSA </li></ul></ul><ul><li>State Requirements </li></ul><ul><ul><li>Verified earned income subject to FICA/SECA </li></ul></ul><ul><ul><li>Kansas resident </li></ul></ul>
    21. 21. WORK Eligibility <ul><li>Consumers must meet the Working Healthy eligibility requirements, plus: </li></ul><ul><li>Eligible for the Physical Disability, Developmental Disability, or Traumatic Brain Injury Waivers, or </li></ul><ul><li>On the waiting lists for these waivers, or </li></ul><ul><li>Meet the same level of care as individuals on these waivers, and </li></ul><ul><li>Competitively employed in an integrated setting, and </li></ul><ul><li>Residing in a home or property that is not owned, operated, or controlled by a provider of services not related by blood or marriage </li></ul>
    22. 22. Working Healthy/WORK Benefits <ul><ul><li>Full Medicaid coverage </li></ul></ul><ul><ul><li>Personal and other services for those who need them </li></ul></ul><ul><ul><li>Countable earned income up to 300% Federal Poverty Level </li></ul></ul><ul><ul><li>Cash assets up to $15,000 </li></ul></ul><ul><ul><li>Retirement accounts (no limit) </li></ul></ul><ul><ul><li>Individual Development Accounts (no limit) </li></ul></ul><ul><ul><li>Elimination of spend down (Premiums for those >100% of FPL) </li></ul></ul><ul><ul><li>Medicare coverage paid by Medicaid (sometimes employer premiums paid) </li></ul></ul><ul><ul><li>Benefits planning </li></ul></ul>
    23. 23. WORK Services Package <ul><li>Assessment </li></ul><ul><li>Personal Services </li></ul><ul><li>Assistive Services </li></ul><ul><li>Independent Living Counseling </li></ul>
    24. 24. Assessment <ul><li>Determination of a consumer’s need for personal assistance services based on his/her functional limitations </li></ul>
    25. 25. Personal Services <ul><li>One or more persons assisting, or cuing/prompting, consumers with activities of daily living they would typically perform themselves in the absence of a disability </li></ul><ul><li>Alternative and cost-effective methods of obtaining assistance to the extent that expenditures would otherwise be used for human assistance, e.g., meal or laundry service, purchase of equipment that decreases the need for human assistance </li></ul>
    26. 26. Personal Services <ul><li>Work related services include assisting, or cuing and prompting, consumers to understand job responsibilities, in interacting appropriately with other employees and the general public, in appropriate work behavior, in practicing safety measures, in symptoms management </li></ul>
    27. 27. Monthly Allocation <ul><li>Personal Services are paid directly by the consumer with a monthly allocation that is determined during the assessment. </li></ul><ul><li>Flexibility in spending the allocation: </li></ul><ul><ul><li>Wages for assistants can vary based on required tasks, time of day, etc </li></ul></ul><ul><ul><li>Funds can be used to pay for assistant’s vacations or health insurance </li></ul></ul><ul><ul><li>Unspent allocation funds can be rolled over into a designated savings account to be used the next month or for approved savings </li></ul></ul><ul><ul><li>Consumers can be creative! </li></ul></ul>
    28. 28. Assistive Services <ul><li>Assistive Technology not covered under the Kansas Medicaid State Plan </li></ul><ul><li>Services that assist consumers to use assistive technology </li></ul><ul><li>Home modifications </li></ul>
    29. 29. Independent Living Counseling <ul><li>Assisting consumers to: </li></ul><ul><li>develop, and obtain approval for, their Individualized Budgets and Emergency Back-Up Plans </li></ul><ul><li>access training </li></ul><ul><li>locate service providers </li></ul><ul><li>coordinate their services </li></ul><ul><li>report problems </li></ul><ul><li>etc… </li></ul>
    30. 30. Benefits Specialists <ul><li>Collect data on individual’s current benefits status </li></ul><ul><li>Provide a critical analysis of work, earning, and resources on a consumer’s benefits in order to help him/her make an informed choice about employment </li></ul><ul><li>Provide options to the individual and their support network if appropriate about the impact of employment or increased employment on benefits </li></ul><ul><li>Provide information about Working Healthy and WORK </li></ul>
    31. 31. Temporary Unemployment <ul><ul><li>Working Healthy has a six months “grace” period. Consumers may remain in the program for six months while they seek employment or recover </li></ul></ul>
    32. 32. Reasons for WORK <ul><li>The DRA Benchmark Benefits provision, under which WORK was authorized, provided the most flexibility for designing an innovative program that meets the needs of a working population requiring personal assistance services to work and live in the community. </li></ul><ul><li>The Kansas Health Policy Authority (KHPA), which administers Medicaid in Kansas, believes that Working Healthy , combined with the WORK services necessary to support employment, will increase the number of Kansans with disabilities who are employed. </li></ul><ul><li>Unlike most waivers, WORK allows consumers with various disabilities, including developmental disabilities, to be served within the same program. KHPA believes this will promote competitive, integrated employment for adults with developmental disabilities. </li></ul>
    33. 33. Reasons for WORK <ul><li>WORK provides consumers with the ability to “control” their services, rather than to just “direct” them, potentially increasing consumer satisfaction. </li></ul><ul><li>WORK permits direct cash payments to consumers to pay for their services, which may facilitate more cost-effective decision-making regarding services and service providers. </li></ul><ul><li>Kansas received a Medicaid Infrastructure Grant to Support the Competitive Employment of People with Disabilities, and believes that WORK will contribute to success in meeting employment goals. </li></ul>
    34. 34. Cash & Counseling: An Innovative State Program Congressional Briefing on Health and Disability Policy July 12th, 2007 United States Senate Finance Committee William A. B. Ditto, Director Division of Disability Services New Jersey Department of Human Services
    35. 35. Cash & Counseling: Program Overview <ul><li>Funders </li></ul><ul><ul><ul><li>The Robert Wood Johnson Foundation </li></ul></ul></ul><ul><ul><ul><li>US DHHS/ASPE </li></ul></ul></ul><ul><ul><ul><li>Administration on Aging </li></ul></ul></ul><ul><li>Waiver and Program Oversight </li></ul><ul><ul><ul><li>Centers for Medicare and Medicaid Services </li></ul></ul></ul><ul><li>National Program Office </li></ul><ul><ul><ul><li>Boston College Graduate School of Social Work </li></ul></ul></ul><ul><li>Evaluator </li></ul><ul><ul><ul><li>Mathematica Policy Research, Inc. </li></ul></ul></ul>
    36. 36. Original Cash & Counseling Demonstration Overview <ul><li>Original Demonstration States </li></ul><ul><ul><ul><li>Arkansas, Florida, New Jersey </li></ul></ul></ul><ul><li>Study Populations </li></ul><ul><ul><ul><li>Adults with disabilities (Ages 18-64) </li></ul></ul></ul><ul><ul><ul><li>Elders (Ages 65+) </li></ul></ul></ul><ul><ul><ul><li>Florida: Both groups above & children with developmental disabilities </li></ul></ul></ul><ul><li>Feeder Programs </li></ul><ul><ul><ul><li>Arkansas and New Jersey: Medicaid personal care option programs </li></ul></ul></ul><ul><ul><ul><li>Florida: Medicaid 1915c Home and Community-Based long-term care waiver programs </li></ul></ul></ul>
    37. 37. Original (3) and Expansion(12) Cash & Counseling States
    38. 38. <ul><li>Consumer Directed Services Definition: </li></ul><ul><ul><li>A philosophy and orientation to the delivery of services whereby informed consumers assess their needs, determine how these needs should be met, determine who can best meet them and monitor the quality of services received. The consumer exercises substantial control over the resources available to meet their needs. </li></ul></ul>
    39. 39. Basic Model for Cash & Counseling <ul><li>Step 1: Consumers receive traditional assessment and care plan </li></ul><ul><li>Step 2: A dollar value is assigned to that care plan </li></ul><ul><li>Step 3: Consumers receive enough information to make unbiased personal choice between managing individualized budget or receiving traditional agency-delivered services. </li></ul>
    40. 40. Basic Model for Cash & Counseling <ul><li>Step 4: Consumer and counselor develop spending plan to meet consumer’s personal assistance needs </li></ul><ul><li>Step 5: Individual provided with financial management and counseling services (supports brokerage) </li></ul><ul><li>Note: Can make use of a representative or surrogate decision maker, if desired. </li></ul>
    41. 41. New Jersey Personal Preference Program <ul><li>Reasons New Jersey Implemented Program </li></ul><ul><li>Demographics </li></ul><ul><li>Prudent Purchasing/Effective Use of Resources </li></ul><ul><li>Consumer Empowerment </li></ul><ul><li>Increase Personal Responsibility </li></ul><ul><li>Address Consumer Complaints & Lack of Flexibility </li></ul><ul><li>Support of Family Caregivers </li></ul>
    42. 42. New Jersey Personal Preference Program <ul><li>Details of Program Design </li></ul><ul><li>Utilizes a Section 1115 Research & Demonstration Waiver </li></ul><ul><li>Cashes out NJ Medicaid Personal Care Benefit (Optional State Plan Service) </li></ul><ul><li>Individual Budget Based on Standard Clinical Assessment </li></ul><ul><li>Rates are $15.50 weekdays, $16.00 holidays & weekends </li></ul><ul><li>10% Deduction to Cover Cost of Fiscal Employer Agent and Counseling Services (Maintains Cost Neutrality) </li></ul>
    43. 43. New Jersey Personal Preference Program <ul><li>Details of Program Design </li></ul><ul><li>Participant Designs Cash Management Plan (CMP) with assistance from Counselor </li></ul><ul><li>Can Select & Use Unpaid Representative to help </li></ul><ul><li>Participant Serves as “Employer of Record” </li></ul><ul><li>Participant Recruits, Hires, Determines Pay & Benefits for Workers </li></ul><ul><li>Workers can be Family, Friends or Others </li></ul><ul><li>Individual Budget can also be Used for Purchasing Services, Equipment and Home Modifications related to meeting Personal Care Needs </li></ul>
    44. 44. New Jersey Personal Preference Program <ul><li>Details of Program Design </li></ul><ul><li>Fiscal Employer Agent/FEA (also known as Fiscal Intermediary Service Organization) handles all payroll and other payments </li></ul><ul><li>FEA claims Medicaid Funds each Month and Maintains Individual Account for Participant </li></ul><ul><li>Counselor visits Participant Quarterly to Monitor </li></ul><ul><li>Nurse Reassesses Participant Every Six Months </li></ul>
    45. 45. Policy Implications For Workers with Disabilities <ul><li>Provides opportunities to hire co-workers and friends to provide workplace PAS </li></ul><ul><li>Enables participants to control when and how services are delivered </li></ul><ul><li>Budget can be used to purchase equipment or devices to increase independence in the workplace </li></ul><ul><li>May reduce employer concerns about job accommodations </li></ul>
    46. 46. General Policy Implications <ul><li>Can increase access to care </li></ul><ul><li>Greatly improves quality of life (all ages) </li></ul><ul><li>Family caregivers also benefit greatly </li></ul><ul><li>Community integration is enhanced </li></ul><ul><li>Consumers are prudent purchasers </li></ul><ul><li>It Works !!!!! </li></ul>
    47. 47. Deficit Reduction Act (PL 109-171) February 8, 2006 <ul><li>States traditionally needed to use Section 1115 (Research & Demonstration Waivers) or Section 1915(c) (Home & Community Based Waivers) to offer Cash & Counseling </li></ul><ul><li>Section 6087 of the Deficit Reduction Act (DRA) is entitled: </li></ul><ul><li>Optional Choice of Self Directed Personal Assistant Services </li></ul><ul><li>(Cash and Counseling) </li></ul><ul><li>This provision became effective 1/1/07 </li></ul>
    48. 48. Deficit Reduction Act (PL 109-171) February 8, 2006 <ul><li>One potential impediment for States: </li></ul><ul><li>Section 6087 (j)(6) </li></ul><ul><li>“ . . . Payment for the activities of the financial management entity shall be at the administrative rate established in Section 1903(a).” </li></ul>
    49. 49. For more information: or William A. B. Ditto, Director NJ Personal Preference Program New Jersey Division of Disability Services [email_address]
    50. 50. Personal Choices Offering Consumers Choice and Flexibility
    51. 51. Alabama first state to make consumer-directed (also known as self-directed) care for Medicaid home and community-based services a permanent part of its State Plan. Alabama worked closely with Centers for Medicare and Medicaid Services to ensure successful completion of the application. Consumer-Directed Care in Alabama
    52. 52. DRA 2005 <ul><li>The state plan option is available to states under the Deficit Reduction Act (DRA) of 2005, Section 6087 or 1915(j) </li></ul><ul><ul><li>1915 (j) is specific to self-directed care, such as the Personal Choices program, to offer consumers more control in managing their daily lives </li></ul></ul>
    53. 53. Program Value <ul><ul><li>Budget-neutral </li></ul></ul><ul><ul><li>Offers consumer satisfaction and enhanced quality of life </li></ul></ul><ul><ul><li>Reduces unmet care needs, and </li></ul></ul><ul><ul><li>Increases access to authorized services </li></ul></ul>
    54. 54. <ul><ul><li>Increased access to paid personal care </li></ul></ul><ul><ul><li>Increased satisfaction with services </li></ul></ul><ul><ul><li>Increased overall quality of life </li></ul></ul><ul><ul><li>Positive health and safety outcomes </li></ul></ul><ul><ul><li>Decreased stress on families and informal caregivers </li></ul></ul>Expected Consumer Outcomes
    55. 55. Expected Outcomes for the State <ul><li>Making consumer-directed care a permanent part of the State Plan will relieve Alabama of the intensive and repeated waiver renewal process. </li></ul><ul><li>Potential cost reduction and quality improvements </li></ul>
    56. 56. Program Validity Personal Choices program based on “Cash and Counseling” model. Model tested over the past decade in Arkansas, Florida, and New Jersey in partnership with Robert Wood Johnson Foundation and CMS.
    57. 57. Personal Choices Program <ul><li>Allows participants of two of Alabama’s HCBS Waivers to self-direct certain services </li></ul><ul><li>Up to 700 older adults and people with disabilities in seven west Alabama counties eligible to participate </li></ul><ul><li>Program to begin August 1, 2007 </li></ul>
    58. 58. Working Together for Consumers <ul><li>Administering Agency </li></ul><ul><li>Alabama Medicaid Agency </li></ul><ul><li>Operating Agency Alabama Department of Senior Services in partnership with Alabama Department of Rehabilitation Services </li></ul>
    59. 59. Eligible Individuals <ul><ul><li>Must currently receive personal care or personal assistance services under Elderly and Disabled (E&D) Waiver or State of Alabama Independent Living (SAIL) Waiver </li></ul></ul><ul><ul><li>Live in one of the seven pilot counties </li></ul></ul><ul><ul><li>Must accept responsibilities of program participation </li></ul></ul>
    60. 60. Program Integrity <ul><li>Personal Choices designed to ensure the integrity of services provided </li></ul><ul><li>“ Counseling” system plays a crucial role in working with the consumer to prevent fraud and abuse </li></ul><ul><li>Clear definition of goods and services that may and may not be purchased </li></ul><ul><li>Close review of budgets to ensure that only authorized goods are included, and </li></ul><ul><li>Review of workers’ time sheets and participants’ check requests before payment to ensure consistency with the budget plan </li></ul>
    61. 61. One's philosophy is not best expressed in words; it is expressed in the choices one makes ... and the choices we make are ultimately our responsibility. Eleanor Roosevelt