Employment in a Medicaid Environment: State Agencies’ Strategic Investment in System Improvements to Increase Employment Outcomes APSE June 2012 Rie Kennedy-Lizotte National Association of State Directors of Developmental Disability Services (NASDDDS) Suzzanne Freeze Institute for Community Inclusion, University of Massachusetts Boston (ICI) 1

Be Informed Medicaid supports employment as an outcome of Home and Community Based Waiver Services for all populations. 2

Be Informed Knowing is not enough; we must apply. Willing is not enough; we must do. Johann Wolfgang won Goethe 3

1915 (c) Waiver Technical Guidance Revisions Released as Information Bulletin September 2011 Highlights the importance of competitive work for people with and without disabilities and CMS’ goal to promote integrated employment options through the waiver program Supports states’ efforts to increase employment opportunities and meaningful community integration for waiver participants Provides further clarification of CMS guidance regarding existing core service definitions and new core service definitions 4

It is all about: Everyday jobs within the general workforce. 5

Key Updates to CMS Waiver Guidance: Provides a strong preamble that highlights the importance of competitive work and CMS’ goal to promote more integrated employment options in waivers Emphasizes the critical role of person-centered planning in achieving employment outcomes 6

Key Updates to CMS Waiver Guidance: continued Clarifies that pre-vocational services are not an end point, but a time-limited activity to help someone obtain competitive employment Describes that volunteer work and other activities that are not paid, integrated community employment, are appropriately classified as pre-vocational, not supported employment services 7

Key Updates to CMS Waiver Guidance: continued Articulates best practices and highlights self-direction options for employment support, including self- employment, peer to peer, co-worker support… Explains that Ticket to Work Outcome and Milestone payments are not in conflict with payment for Medicaid services rendered 8

Key Updates to CMS Waiver Guidance: continued Splits supported employment into two core service definitions- individual employment support and small group employment support (2 to 8 people) Adds a new core service definition for career planning, that is currently used by several states 9

Medicaid and Employment Guidance to States CMS did not change policy, but rather was clarifying and strengthening Guidance around permissible waiver options to promote employment for people with disabilities and individuals who are elderly These changes will also be included in version 3.6 of the Waiver Technical Guide to be released at a later date. 10

Affordable Care Act Affordable Care Act Section 2403: Money Follows the Person (MFP) Demonstrations, provides opportunities for States to promote and support employment through program administration, policies and services. States also have opportunities within their rebalancing funds to support employment related services and activities. 11

Affordable Care Act Section 10202: Balancing Incentive Program offers a targeted FMAP increase to States that undertake structural reforms to increase access to HCBS. Effective October 1,

Affordable Care Act Community First Choice Option - Adds Section 1915(k) to the Social Security Act, includes a 6% enhanced FMAP statewide, community services (not institutions) CFC is an optional State plan benefit which utilizes a person-centered plan and allows for provision of services to be self-directed under either an agency-provider model or a self-directed model with a service budget. The benefit can be used to support an individual’s employment goals. 13

Affordable Care Act Section 2402 of the Affordable Care Act allows States to expand access to Home and Community-Based Services without requiring institutional level of care for enrollees. Known as the 1915 (i) State plan option 14

States take different approaches Nebraska – has a three-month service limit to focus on concentrated time to plan for job development Wisconsin – if an individual uses prevocational services they must define exactly what they intend to get out of it and how long it will take them (limits use of sheltered workshops as a setting for long-term prevocational services 15

States take difference approaches Colorado - added career planning as a service type with specific and deliberate activities – in CMS language it this is prevocational services, and no longer allow prevocational services to be delivered in a sheltered employment environment Maryland - offers Employment and Customization as a service which includes detailed person-centered planning process, and annual assessment of the individual’s employment goals 16

States take difference approaches How are states being asked to describe integrated employment goals in waiver renewals? New challenges – the bar is being raised. 17

States take difference approaches Collaborative efforts with other public systems such as vocational rehabilitation and education. 18

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Readiness Model: What the heck does that mean anyway? When is someone ready to start their working career? Most of us find out what we need to know during our after-school and weekend jobs. The only criteria for knowing if we are ready for the “world of work” is by trying it. 20

“If you treat an individual as he is he will stay as he is. But if you treat him as if he were what he ought to be, he will become what he ought to be.” -Goethe 21

Using data to promote better employment outcomes 22

Questions 23

Contact Information Rie Kennedy-Lizotte NASDDDS Suzzanne Freeze ICI/UMass Boston