1. Iowa E1st Community of Practice May 17, 2016

2. Employment First Managed Care Employment Service Re- Design CMS Settings Rule

3.  All services must be provided in integrated community settings.  Integrated community settings are places that: ◦ Support access to the greater community ◦ Provide opportunities to seek employment and work in competitive integrated settings ◦ Provide opportunities to engage in community life ◦ Provide opportunities to control personal resources ◦ Give people receiving services the same access to the community as those who aren’t receiving services  MCOs take compliance very seriously.

5.  One MCO responsible for a person’s ◦ Acute/Primary Medical Care ◦ Behavioral Health Care ◦ Long-Term Services and Supports  Why integrate through managed care? ◦ Improve coordination and duplication – save money and produce better outcomes ◦ Removes system silos ◦ One entity managing all services - incentivizes investments in services/strategies that reduces costs and produce better outcomes in other parts of system

6.  Easier to coordinate and reduce duplication and generate savings states expect if managing it all  Recognize LTSS services can have very positive impact on health status, reducing health care needs and costs

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9.  Issued May, 2013: ◦ “Summary - Essential Elements of Managed Long Term Services and Supports Programs” ◦ “Community based LTSS should be delivered…in a way that offer the greatest opportunities for active community and workforce participation.” ◦ “CMS expects states to assure that managed care networks meet the needs of MLTSS beneficiaries, including adequate capacity and expertise to provide access to services that support community integration, such as employment supports” 9

10.  Proven bi-directional relationship between employment and health ◦ Employment contributes to better health ◦ Better health contributes to participation in employment  Employment contributes to prevention of - and recovery from - mental illness  Employment is associated with greater skills in activities of daily living (ADLs) 10

11.  Other systems can be leveraged to support people to obtain/maintain integrated employment  Employment creates opportunities to build & use natural supports  Employment enhances income –people can contribute to the cost of their supports  Employment can offer access to employer- sponsored health care 11

12.  MCOs get that Employment First and employment systems change is a high priority nationally.  MCOs know that Supported Employment is what youth and their families want.  MCOs are in states that are already expecting them to improve integrated employment outcomes. 12

14.  If its not cost-effective as compared to alternative service costs and outcomes ◦ If rates appear to be substantially higher than for alternative services, but utilization is expected to be similar and outcomes are not significantly different.  Members not responding positively to MCO efforts to encourage integrated employment as a goal (MCOs can’t get people to say “YES, I want to work and I want a job.” 14

15.  If MCO staff don’t have sufficient knowledge and experience with Supported Employment services  If service authorization processes are more cumbersome and service coordination takes more time if a person chooses Supported Employment  If Supported Employment providers can’t or won’t offer holistic daytime supports to members who need it 15

17.  HCBS Setting Standards include: Settings must “provide opportunities to seek employment and work in competitive, integrated settings.”  Applies to all HCBS settings – nothing in regulations suggest otherwise.  Help MCO’s understand what needs to be expected of providers of non-employment services (including residential, transportation, day services) so they are not a barrier to people seeking employment and working in the community.

18.  How to work with a member to get the member (and family/guardian if involved) to say YES to working in integrated employment.  How/when to engage IVRS and when to be prepared to take over from IVRS.  Help defining the kinds of provider contract provisions that will incentivize and reward best practice Supported Employment services

19.  Offer holistic supports that are community- based. ◦ Supports while career exploration and job search is going on (“in the meantime” services) ◦ Supports to wrap around a part-time job ◦ Supports if people lose their jobs unexpectedly ◦ Cost-effective transportation solutions (not necessarily the SES agency/staff providing this)

20.  Offer to provide training to MCO staff on how Supported Employment services work, best practices, etc.  Offer to partner with them to become a Project Search site  Offer an employer needs analysis that leads to the MCO hiring people through Customized Employment  Help MCOs reach out to their suppliers (accounts payable list) to engage them around hiring people with disabilities

21.  Contracts matter: Before you engage the MCOs, know what is in their state contracts that relates to integrated employment. Connect what you want with what they are expected to do by the state…help them see it can be a “win-win”.  Engage MCOs now: Employment Service Re- Design being implemented now; confirm your support for these changes, offer to meet to explain history if you have been involved.

22.  Educate MCOs on the Validity of the Reimbursement Rates in Employment Service Re-Design ◦ Higher SES reimbursement rates will bring better employment outcomes for individuals served ◦ Integrated Employment results in less dependency on paid services over the long-term; lower costs ◦ Integrated employment results in better outcomes for the person- share impact on people you serve

23.  Learn about each MCO’s Value-Added Benefits ◦ Which MCOs are offering Value Added Benefits focused on integrated/supported employment? ◦ Are there any suggestions for modifications you would make in light of the Employment Re-Design changes?  https://dhs.iowa.gov/sites/default/files/Valu eAddedServicesComparisonChart_2015_12_0 2.pdf https://dhs.iowa.gov/sites/default/files/Valu eAddedServicesComparisonChart_2015_12_0 2.pdf

24.  Transitions to managed care are always rough in the beginning – tragedy is it creates so much negativity between partners from the outset  Open dialogue with MCOs if they aren’t coming to you around Employment Service Re-Design  Join with other providers, this CoP, Iowa APSE or IACP, or another organized group to bring your recommendations to them and offer to be a constructive partner

25. Every good thing that has happened in our life happened because something changed. -Andy Andrews

26. Lisa A. Mills, PhD Disability Employment Systems Change Consultant Employment First State Leadership Mentoring Project LisaMills@mtdd.onmicrosoft.com 608 225 4326 2707 Mason Street Madison, Wisconsin 53705