PLANNING FOR TRANSITION TO ADULT PROGRAMS: Habilitation Supports Waiver vs. MI Choice Waiver

1. PLANNING FOR TRANSITION TO ADULT PROGRAMS:Habilitation Supports Waivervs. MI Choice Waiver Elizabeth Gallagher, MI Choice Program Manager Deb Ziegler, HSW Program Manager September 8, 2010

2. TODAY’S FOCUS The special issues for people who will be turning age 21 and no longer eligible for private duty nursing through the Medicaid State Plan with in-depth information about the MI Choice since this audience is very familiar with the HSW

3. PUTTING THE PUZZLE TOGETHER • WHEN should transition planning begin? • WHO should be involved? • WHAT do we need to know about the different programs? • WHERE do we go to ask for services? • HOW do we help the person choose the ‘best’ program?

4. ACRONYMS ADL: Activities of Daily Living IADL: Instrumental Activities of Daily Living CSHCS: Children’s Special Health Care Services CM/SC: Case Manager, Care Manager, or Supports Coordinator DD: Developmental Disability HSW: Habilitation Supports Waiver ID: Intellectual Disability LOC: Level of Care PDN: Private Duty Nursing

5. NFLOC Nursing Facility Level of Care To be eligible for the MI Choice waiver, applicants must meet the NFLOC . This is a set of functional and medical criteria one must meet to qualify for a Medicaid-funded nursing facility stay. Applicants for the MI Choice waiver must demonstrate that they meet this same criteria. Most applicants qualify by needing assistance with their ADLs. Home and Community Based Waivers enable states to provide services to Medicaid beneficiaries in the community who would other need institutional level of care. The MI Choice Waiver has NFLOC as the alternative institutional level of care.

6. ICF/MR Intermediate Care Facility for the Mentally Retarded To be eligible for the HSW, an individual must require the LOC provided by an ICF/MR if not for waiver services. This means an individual with a DD/ID would otherwise need an active treatment program of specialized and/or generic training, treatment, health and related services directed toward the acquisition of behaviors necessary to function with as much self-determination and independence as possible. Home and Community Based Waivers enable states to provide services to Medicaid beneficiaries in the community who would other need institutional level of care. The HSW has ICF/MR as the alternative institutional level of care.

7. MEDICAID STATE PLAN Until age 21, every Medicaid beneficiary who meets medical necessity for PDN is eligible to receive the State Plan service called Private Duty Nursing.

8. HOW DOES SOMEONE GET PDN IF THEY ARE AGE 21 OR OLDER? NOTE: PDN is not available for people living in licensed settings, like adult foster care homes.

9. TRIGGER FOR TRANSITION PLANNING • Aging off PDN state plan services on 21st birthday

10. WHEN SHOULD TRANSITION PLANNING BEGIN? • The first transition planning meeting should be at least 6 months (and better if it’s one year) prior to the 21st birthday. • Transition planning is a series of activities that is finished only when the person enrolls in the program that best meets his or her needs.

11. WHO SHOULD BE INVOLVED? • Initial Meeting: the person, family or friends as identified by the person, guardian if applicable, the CM/SC, and others identified by the person or family • Subsequent Communication (may be in-person or by phone): Those listed above plus representatives of potential programs or providers. • How often: As often as necessary to make sure the person can make an informed decision about which program in which to enroll.

12. STEPS IN THE TRANSITION PROCESS • Identification of Needs • Making Informed Choice • Pursue Referral for Assessment of Eligibility & Services/Supports • Provide close follow-up with family until decision has been made and enrollment has been completed. NOTE: A person cannot be enrolled in both the MI Choice Waiver and HSW. This is because there are two different LOC alternatives.

13. Transition Planning Conference Call • About 6 months before the 21st birthday, the CSHCS Transition Coordinator will assist in setting up a conference call. • Participants: • Person and Family • HSW representative (Deb) • MI Choice representative (Elizabeth) • CSHCS representative (Gina from central office, Public Health nurse) • PIHP representative (HSW Coordinator, SC) • MI Choice representative (Supports Coordinator)

14. Transition Planning Conference Call • Purpose of the call • Make sure all parties are familiar with both MI Choice and HSW and have the same information • Let the family know about the transition process • Address any concerns the family may have with the transition • Answer questions from any of the parties • Enable the family to make an informed choice once they understand the options they have. The family may decide during the call which program they want to apply for or might ask that both programs complete an initial assessment before deciding.

15. WHAT DO WE NEED TO KNOW ABOUT THE DIFFERENT PROGRAMS? WHERE DO WE GOTO ASK FOR SERVICES?

16. OVERVIEW OF MI CHOICE The MI Choice Waiver Program is designed to enable the elderly and younger disabled adults (age 18 & older) to remain at home and to participate in their communities. The waiver serves approximately 10,500 adults each year.

17. MI CHOICE ELIGIBILITY REQUIREMENTS • Must meet nursing facility level of care (NFLOC) • MI Choice waiver agents must apply the Michigan Medicaid Nursing Facility Level of Care Determination tool to persons applying for enrollment in the program • Applicants must pass through one of the seven “doors”

18. MI CHOICE ELIGIBILITY REQUIREMENTS (cont’d) • Applicant must demonstrate, through the assessment process, the need for at least one MI Choice waiver service • Waiver participants must receive at least one MI Choice service on a regular basis to maintain program eligibility.

19. FINANCIAL ELIGIBILITY FOR MI CHOICE WAIVER • Must be eligible for Medicaid • Maximum income is 300% SSI or $2,022/month GROSS in calendar year 2010 • Spousal protections apply • Waiver participants are considered a group of one • Waiver participants do not have a spend-down

20. ADDITIONAL INFORMATION FOR MI CHOICE WAIVER • Waiting lists are managed with four priority categories. These categories are listed below in descending priority: • Adults aging off of Medicaid State Plan Private Duty Nursing whose services are authorized by Medicaid Program Review Division • Nursing Facility residents • Persons with active Adult Protective Services cases or Persons at imminent risk of nursing facility placement • All other applicants by date of inquiry

21. RESOURCES FOR MI CHOICE • To find a local waiver agent or for more information on the MI Choice Waiver: www.michigan.gov/mdch • Click on “Health care coverage.” • Click on “Services for seniors.” • Click on “Choices for older or disabled persons who may need help caring for themselves.”

22. REFERRAL TO MI CHOICE • Persons interested in enrolling in MI Choice must work with a waiver agent that serves their county of residence.

23. REFERRAL TO MI CHOICE WAIVER • Many waiver agents have waiting lists; HOWEVER, • Adults aging out of CSHCS who also require PDN services receive priority and should not be placed on the waiting list.

24. REFERRAL TO MI CHOICE (cont’d) • Ask for an assessment of eligibility for MI Choice waiver services. • An intake specialist will conduct a pre-screen over the phone • If applicant passes the pre-screen, the specialist will schedule an in-person assessment.

25. MI CHOICE & CSHCS AGE-OUTS MI Choice Program Manager notifies waiver agent at least 12 months ahead of a CSHCS age out. • In-home assessment should be completed by the waiver agent within 7 days of contact • If waiver agent has waiting list, this may take longer • CSHCS age-outs should not have to wait. • If neither of these occur, contact Elizabeth Gallagher at 517-335-5068 or GallagherE@michigan.gov

26. APPLICANT’S RIGHT TO APPEAL • Waiver agent must inform applicant of their right to appeal throughout the process • If applicant put on waiting list • If applicant does not pass telephone screen • If applicant does not meet NFLOC • If applicant does not meet other enrollment criteria

27. MI CHOICE ENROLLMENT • If CSHCS age out, usually on 21st birthday, may be sooner if need MI Choice services other than PDN • Can still receive all State Plan Services including mental health services through the PIHP, but careful coordination must occur so there is no duplication of services. • Must obtain Personal Care services through the waiver agent

28. MI CHOICE ENROLLMENT • Two Options for Service Delivery • Traditional/Agency Based • All workers must be employed by an agency in the waiver agent’s provider network. • Self-Determination • Can choose own workers • Workers cannot be legally responsible for participant (i.e. spouse or guardian) • Participants can use a mixture of Traditional and Self-Determined services

29. OVERVIEW OF HSW The purpose of the HSW is to enable people of any age who have a DD to live and participate as productive members of their communities instead of living in institutions. This waiver serves approximately 8,000 people each year.

30. ELIGIBILITY REQUIREMENTS FOR HSW • Must have a DD • Must be living in the community while receiving HSW services • Without HSW services, would otherwise require ICF/MR level of care • Must be eligible for Medicaid • Must receive at least one HSW service each month

31. ADDITIONAL INFORMATION FOR HSW • Part of the managed care mental health system • First priority for enrollment given equally to young adults aging off CWP and individuals discharged from ICF/MR. • We do also try to prioritize people aging off state plan PDN if they are eligible to enroll in & choose HSW. • PDN providers must be enrolled in the PIHP network if the person will be receiving PDN services through the HSW.

32. REFERRAL TO HSW • The person or his/her legal representative contacts the Access Center through the PIHP or local CMHSP • Request an intake assessment to determine eligibility for DD services • PIHP initiates assessment within 14 days of request • If eligible for DD services, PIHP completes an individual plan of services to determine amount, scope and duration of services to be provided • PIHP submits an application for HSW enrollment • If not eligible, the PIHP notifies the person of his/her right to fair hearing

33. RESOURCES FOR HSW • Go to the Medicaid Provider Manual on the internet at: http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf Click on the Mental Health and Substance Abuse Chapter, Section 15.

34. HOW DO WE HELP THE FAMILY CHOOSE THE ‘BEST’ PROGRAM? • Decision which program to enroll in must: • consider the unique needs and desired outcomes of the individual and family; • use the person-centered planning process; • be based on clear, comprehensive, accurate information about both programs and the services each can offer so the individual and family can make an informed choice; • include timely assessments, determine eligibility and medical necessity for the services; and • for HSW, determine whether the person needs and wants to participate in at least one habilitative service in addition to receiving PDN.

35. MI CHOICE PDN is a service for adults w/ physical disabilities age 21+ Otherwise needs NFLOC Exempt from enrolling in Medicaid Health Plan Must need at least one MI Choice waiver service per month If personal care is needed, must obtain through MI Choice. HSW PDN is a service for adults with DD age 21+ Otherwise needs ICF/MR Level of Care Not exempt from enrolling in Medicaid Health Plan Must participate in one habilitative waiver service in addition to PDN If personal care is needed, must obtain from Home Help (thru DHS) Offers some services not available in MI Choice COMPARISON OF MI CHOICE AND HSW

36. Providing the person and family with information about the different features of each program and assisting with securing the necessary assessments or other intake requirements, the person can find the set of supports and services that is the “best fit” to meet his or her needs and help to achieve future goals.

37. QUESTIONS ABOUT TRANSITION PLANNING IN THE ‘REAL WORLD’ ?

38. CONTACT INFORMATION • Elizabeth Gallagher, MI Choice Program Manager 517-335-5068 or gallaghere@michigan.gov • Deb Ziegler, HSW Program Manager 517-241-3044 or zieglerd@michigan.gov