1. 1 Patrick Stephan July 16, 2010 Flexible Supports Waiver

2. 2 FSW Overview Disclaimer: * Everything contained within this presentation, represents draft concepts and work completed to date – it is NOT an indication of anything being set in stone.

3. 3 FSW Overview Current Status Draft (condensed) concept paper sent to JFS and CMS in June and has received good feedback Currently working with the Waiver Sustainability Group on proposed approach Also partnering with Robin Cooper and Sue Flannigan on technical guidance Waiver application is approximately 50% finished Target for initial submission to JFS: September 2010 Shooting for a July 1, 2011 effective date Recent CMS Conference Call

4. 4 FSW Overview County Board will be the ‘front door’ and will retain much of their current duties SSA’s would have continued responsibility with role of Level of Care, ISP, ensuring health & safety, among other things Waiver will offer participant direction Overall cost limit: $25,000/year for children; $40,000/year for adults Overall cost limit means no ODDP, no Prior Authorization Adults are generally defined as: 22 years of age or older

5. 5 FSW Overview Eligibility: –ICF/MR LOC –Pre-Screen Tool –Participant Direction Assessment Number of individuals to be served on the waiver has not been determined yet –Individuals could come from the Waiting List or they could transfer from IO or Level One –Will contact CBs to get a closer estimate on #’s; for the first three years of the waiver –Will set aside slots for Children with Intensive Behavioral Needs and for Hearing Decisions

6. 6 FSW Overview Service Package The proposed service package for the Flexible Supports Waiver consists of: Support Brokerage Functional Behavioral Assessment Psychosocial Services Remote Monitoring Respite (3 types) Adult Day Waiver Services Participant/Family Stability Assistance Remote Monitoring Equipment Community Inclusion (Personal Care, General, transportation) Participant-Directed Goods and Services

7. 7 FSW Overview Rates & Rules: No new rules specific to this waiver –Rules for services already in existence/to-be in existence (i.e., IO Amendment new services) will be amended to include FSW –Otherwise, necessary governing details will be spelled out in the Waiver Application itself Services carried forward from Level 1, or IO would carry forward rates Negotiated Rates within a range for the new waiver services of Psychosocial Services, Community Inclusion, and Support Brokerage HPC is replaced by Community Inclusion –For at least the 1 st year the waiver is in operation, individuals on FSW would not be able to live with individuals on IO or Level One (due to sharing services issue)

8. 8 FSW Overview Two new entities: This waiver will add 2 primary components of participant-direction: –Support Brokerage and –Financial Management Services (Fiscal Intermediary) Both of these entities would exist to assist an individual in directing their own services as well as their budget

9. 9 FSW Overview Support Broker Responsible for providing the individual with representation, advocacy, advice and assistance related to the day-to-day coordination of services (particularly those associated with participant direction) in accordance with the ISP. The Support Broker assists the individual with the individual’s responsibilities around participant direction, including understanding Employer Authority and Budget Authority, and keeping the focus of the services and support delivery on the individual and his/her desired outcomes. Other roles: Negotiating Rates, communication with individual, SSA, FMS

10. 10 FSW Overview Support Brokerage (SB) would be a waiver service (and would be subject to Free Choice of Provider). Proposed Cost Limit for SB: $8,000/year Currently proposing that it is required for the 1 st year the individual is on the waiver Before becoming a Support Broker, must attend training established by DODD The following cannot become a Support Broker: County Boards; CB employees/contractors; FSW providers (and their related entities) In addition, family members and legal guardians cannot be paid to provide this service

11. 11 FLEXIBLE SUPPORTS WAIVER: PARTICIPANT DIRECTION Financial Management Services (FMS) (Fiscal Intermediary) FMS’ purpose is to assist the individual with managing their budget & to take out the necessary taxes/withholding to ensure that the individual’s providers are meeting all State and Federal requirements. If the individual chooses, the FMS could also assist the individual with employer-related functions (i.e., Co-Employer) DODD plans to partner with Ohio’s statewide Financial Management Services entity to provide this function.

12. 12 FSW Overview FMS will be paid for as an administrative activity (not as a waiver service) In Self Directed Waivers, use of a Fiscal intermediary’s is the accepted best practice by CMS County Board will be required to submit authorized services to Support Broker/FMS Tracking of payments, claims and utilization will occur with the FMS FMS will be required to provide the individual, County Board, Support Broker and DODD with a monthly and annual reports related to expenditures, etc.

13. 13 FSW Overview Certification: Participant-Directed Goods and Services –We are proposing that providers of Participant-Directed Goods and Services would not need to become certified Medicaid providers. Community Inclusion – GeneralParticipant/Family Stability Assistance –In addition, if JFS agrees, the Financial Management Services (FMS) entity would execute the Medicaid Provider Agreement on JFS’ behalf for the services of Community Inclusion – General and Participant/Family Stability Assistance –All other services would be required to go through our existing Provider Certification Process

14. 14 FSW Overview Participant Direction Everyone on this waiver will be required to engage in participant direction. Two components: Budget Authority Employer Authority

15. 15 FSW Overview Budget Authority - Allows the individual (or authorized representative) to allocate their budget to waiver services however they choose, and to manage their budget accordingly - An individual must, at a minimum, choose Budget Authority for at least one of the services they select. - We believe that Budget Authority does not apply to the Adult Day Waiver Services.

16. 16 FSW Overview Employer Authority Employer authority option is not mandatory for this waiver Would only be applicable to the following services: –Support Brokerage –Community Inclusion –Participant/Family Stability Assistance –Participant-Directed Goods and Services –Respite (Informal)

17. 17 FSW Overview Employer Authority Allows the individual to hire, fire, direct, manage, etc., their workers –There are two Employer Authority options: Common Law Employer, where the individual is the Employer of Record (meaning the entity that holds the liability for ensuring taxes, unemployment, workers’ comp, etc. are deducted) Co-Employer, where the individual enters into an arrangement whereby a 3 rd party (e.g., the FMS) is the Employer of Record on the individual’s behalf. –FSW will incorporate both options & the individual may choose which one best meets their needs

18. 18 FSW Overview Questions?? Service Package Details

19. 19 FSW Overview Community Inclusion means supports that promote the individual's participation in his/her community. The service includes opportunities and experiences that focus on socialization and/or therapeutic recreational activities, as well as personal growth in his/her home and/or community. Community Inclusion can also include peer support activities and organization of self-advocacy events. The following components define the scope of this service: –Personal Care –Transportation –General (services used by the general public)

20. 20 FSW Overview Respite: Generally, services provided to individuals unable to care for themselves, furnished on a short- term basis because of the absence or need for relief of those persons normally providing the care. 3 types: Informal (as taken from the Level One Waiver) Residential (taken from the IO Amendment) 90 day limitation Community (taken from the IO Amendment) 60 day limitation

21. 21 FSW Overview Participant-Directed Goods and Services means services, equipment, or supplies not otherwise provided through this waiver or through the Medicaid State Plan that address an identified need on the ISP (including improving and maintaining the individual's opportunity for membership in the community) The item or service would: –decrease the need for other Medicaid services; –promote inclusion in the community; –increase the participant's safety in the home environment.

22. 22 FSW Overview All Adult Day Waiver Services will be available under this waiver and the Acuity Assessment Instrument and rates will still apply; however: –An individual cannot be on this waiver and only receive ADWS; –The cost for ADWS will be inside the cap; –FSW may use an “Employment First” requirement whereby justification must be given for an individual to use Adult Day Support or Vocational Habilitation instead of Supported Employment

23. 23 FSW Overview Functional Behavioral Assessment means the process of determining why an individual engages in challenging behavior and how the individual's behavior relates to the environment. These assessments describe the relationship between a skill or performance problem and variables that contribute to its occurrence. Functional behavioral assessments can provide information to develop a hypothesis as to: –why the individual engages in the behavior; –when the individual is most likely to demonstrate the behavior; and –situations in which the behavior is least likely to occur.

24. 24 FSW Overview Psychosocial Services means medical or remedial services recommended by a physician, or other licensed practitioner of the healing arts under State law, for the maximum reduction of physical or mental disability and the establishment of maximum functional level. These services may be provided in the home or in the community. Specific components include, but are not limited, to: –facilitation in development of daily living skills; –social skills training; –development of appropriate personal support networks; –technical assistance and counseling services; and –positive behavior intervention strategies. Service Limitation: This service must be deemed necessary to reduce an individual’s intensive behaviors based on the results of a Functional Behavioral Assessment.

25. 25 FSW Overview Participant/Family Stability Assistance means services that enable the participant/family to understand how best to support the individual in their home and/or to enhance the individual’s ability to direct their own services. The service can only be utilized by the individual or by family members who reside with the individual. Participant/Family Stability Assistance may include counseling and/or training services to the participant/family to accommodate the participant's disability in the home and to access supports offered in the community.

26. 26 FSW Overview Remote Monitoring means the monitoring of an individual in his or her residence by staff using one or more of the following systems: live video feed, live audio feed, motion sensing system, RFID, web-based monitoring system, or other device approved by DODD. Must ensure health and safety. Individuals in the residence must give informed consent for the service to be used in the home whether directly receiving the service or not.

27. 27 F LEXIBLE S UPPORTS W AIVER Thank you