Developing Individual Budgets for Use in Self-Determination in the Michigan Mental Health System

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Developing Individual Budgets for Use in
Self-Determination in the Michigan Mental
Health System

• Self-Determination Leadership Development Seminar
• September 22, 2009

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Individual Budget Definition

• From the Self-Determination Policy, the budget
  is
• A fixed allocation of public mental health funds
• Derived from the costs of needed services
  supports
• May also include other public resources to be
  accessed and integrated through the CMHSP
• Denoted in dollar terms as well as services
• Agreed to by the individual and the CMHSP as the
  necessary cost of services and supports needed to
  accomplish a consumers plan of
  services/supports.

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Individual Budget

• In accordance with the Self-Determination Policy
• The budget is expected or estimated costs of a
  concrete approach to accomplishing the consumers
  plan (Item II-C)
• Developed in conjunction with development of a
  plan of specialty mental health services and
  supports, using a person-centered planning
  process (II-A)
• The amount of the budget shall be formally
  agreed to by both the consumer and the CMHSP
  before it may be authorized for use (II-D)

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MDCH EXPECTATION

• However it is derived
• If the individual does not have direct control
  over a fixed amount of resources so as to be able
  to select and direct providers
• If the individual does not know what the budgeted
  amount is, and what it is intended for
• It aint self-determination
• An individual budget must be sufficient for the
  consumer to accomplish the goals and outcomes
  contained in their plan of services and supports
• The pathways to achieving those may be varied

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Putting the Individual Budget Development Process
into Context

• We live work in a world of limited resources -
  -
• For agency supports coordinators and managers,
  gatekeeping is an expected role
• Somewhere between the organizations need to
  conserve resources and the individuals desire
  for their own share is a middle ground
• How do we get there?
• What is sufficient?
• How do we assure fairness?
• How do we empower participants?
• When the individual knows what s/he has to work
  with, and the basis for that amount, it is rather
  easy to learn how to effect control, eventually

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Goal To Establish Arrangements that Support
Self-Determination

• Authority over resources is not an end by itself
• But control over money is the central element of
  a power shift from others being in charge of
  ones life course, to personal self-determination
• The specific methods to assure direct participant
  choice of and control over providers are not so
  important
• But providing authority for choosing and
  influencing provider behavior is the purpose of
  the mechanics involving arrangements that support
  self-determination
• An individual budget, therefore, is a central
  piece of the machinery of those arrangements
• So is the manner in which the individual is
  supported to apply the individual budget

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From TheParticipants Perspective

• The budget must be
• Accessible
• Flexible
• Portable

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Accessible

• The amount and purpose of the budget is known and
  understood by the participant
• The participant and his or her allies have been
  fully involved in its development
• The participant understands the options (and
  limitations) for applying the budget
• The participant knows has been oriented on how to
  use those funds and provided with a connection to
  where the funds are lodged
• Ongoing information is provided to the
  participant and chosen allies on the status of
  the budget (monthly)

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Flexible

• Options are provided for modifying the budget
  components within the overall amount, including
• Planning is flexible in accordance with how a
  person chooses to live day to day
• Scheduling the amounts of specific
  service/support may vary day to day, week to
  week
• The actual use of a given service/support may be
  varied, in the end, in comparison with the
  original plan
• i.e. the participant may adjust their own service
  dose
• There are opportunities to redirect savings that
  may result from lower-than-planned use of
  services/supports, to other more preferable
  services/supports options
• May be preliminarily authorized on a contingency
  basis in the plan, or
• Plans may be adjusted later on
• Communication needs to be ongoing

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Portable

• It must be possible for the participant to
  manipulate and transfer budgeted resources, from
  one provider arrangement to another.
• Participant must be permitted change fiscal
  intermediaries, with in a framework defined by
  the PIHP/CMSHP
• Budget savings can be maintained within a
  reasonable framework

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Informed of Options

• Participants must be informed of the options for
  flexibility and portability
• Participants must be provided with guidance
  about the types of variations they may initiate
  and the types that will require prior approval
• Including expectations that these must be
  communicated to the PIHP/CMHSP
• Informed in writing
• A how-to guide
• Ongoing guidance is easily accessible
• A Specialist
• Peers
• Fiscal intermediary

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Two Different Approaches for Determining
Individual Budget Amounts

• Retrospective Method
• Benefit amount is determined in response to PCP
• Participant Identifies needs within PCP
• Agency (alone or in concert with participant)
  determines benefit amount, services supports
• Participant determines spending plan,
  implementation strategy

• Prospective Method
• Benefit amount is determined in advance of PCP
• Objective assessment of need determines IB
• Participant determines spending plan, services,
  supports implementation strategy

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Prospective/Retrospective Budgeting
Participant Enters System
Assessment completed using PCP principles
Retrospective Budgeting
Prospective Budgeting
PCP Completed
Total dollar amount of benefit determined
Total dollar amount of benefit determined
PCP completed
Amount of Budget that is self-directed
Services support goals in PCP
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Retrospective vs Prospective

• Michigan uses a retrospective method to determine
  the amount of an individual budget
• First, the plan of services and supports is
  developed
• Then, the amount of the budget is determined
  based upon the costs of services outlined in the
  plan
• A prospective method typically involves using
  assessment and other data to determine the amount
  of the budget, following which a plan of services
  supports is developed that may not exceed the
  prospectively determined amount
• In Michigan, use of an assessment to determine
  services authorization may not be substituted for
  the person-centered planning process
• The prospective method involves a budget cap we
  do not cap budgets on the front end
• But limits on each individual budget developed
  are going to come form somewhere
• In the end, the agreement by the participant is
  to implement the plan within the overall budget
  amount

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Per CMSThe Individual Budget

• Value () of services supports under the
  control direction of the participant
• May include Medicaid Non-Medicaid
  services/supports but must have clear audit trail
  of Medicaid

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CMS EXPECTS STATES TO ADDRESS THESE ISSUES
REGARDING IB

• Describes the method for calculating based on
  reliable costs or services utilization
• Developed using a consistent methodology for all
  involved participants
• Reviewed monitored according to a specified
  method frequency
• Provides participant ability to move money
  around
• Methodology is open to public inspection
• Informs participant of amount that is authorized
  to be self-directed
• Defines a process for making adjustments
  informs participant
• Provides procedures to evaluate over under
  expenditures
• Provides prompt mechanisms to adjust funding in
  response to individual situations

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BUDGET Development Process

• First, the plan is developed using a
  person-centered planning process
• Second the budget amount is determined from the
  plan, calculating costs per unit of service at
  specific rates and aggregating these costs
• Finally, the specific arrangements the
  participant will, or may, utilize to control and
  direct providers are determined
• Then, the budget may be authorized in
  companionship with the plan

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Developing the Plan

• Person-centered planning
• Involves the persons whole life
• Addresses health, welfare and opportunity for
  integration, participation and productive
  activity
• Services needed are authorized with equity in
  mind
• Service authorizations are provided in specific
  form with respect to the amount, duration and
  scope of each service
• Bringing in the cost issues too soon will corrupt
  the process of determining and fairly meeting
  individual needs

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The Budget

• Person-centered planning
• About the persons whole life (NOT just the
  services to be obtained through the MH system)
• Planning a budget takes into account the persons
  whole resource picture
• Entitlements
• Earnings
• In-kind contributions from allies
• CMHSP-provided resources
• Saving money is not a primary goal
• Ratcheting down on opportunity or working outside
  of fairness and equity is not acceptable
• Obtaining better value is ongoing
• Examining costs versus outcomes
• Facilitating a learning process whereby new
  options for achieving outcomes are at the heart
  of improving value

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Calculating the Budget Amount

• In simplest case
• Services authorized are at a static, known level,
  and the person is not seeking a change
• Services are to be provided from among a group of
  known providers with known rates
• The budget is rather straightforward
• Choice and control may be contracted through the
  CMHSP
• But, there is a defined individual budget, the
  person has participated in its development, has
  agreed to the amount, and may access the budget,
  based upon agreements reached in the planning
  process, using a fiscal intermediary

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SUPPORTS PLANNING GRID
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Calculating the Individual Budget

• More complicated
• The person is moving into a role that is new
  (e.g. independent living)
• The services are to be consumer-controlled via
  direct contracts that the consumer will negotiate
• Providers are not looking so traditional
• E.g. individual personal assistance providers
  rather than agency-provided Pas
• Rates to be authorized do not include the same
  cost factors
• Innovative provider arrangements are sought
• Incentivised approaches to obtaining work
• Companionship models that provide some of the
  personal assistance
• Peer support services
• Rates are different

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Rates for Services

• They may not be excessive
• They must be sufficient for the participant to
  acquire qualified and capable providers
• Wage rates
• Must be sufficient
• Necessary add-ons
• Workers compensation
• Training needs
• Health care if possible
• Guidance must be provided to the participant
  regarding the range of applicable rates
• Maximum amounts that the consumer may spend to
  pay specific providers may be specified by the
  CMHSP (III-B-3-e)

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Once the Budget is Agreed To

• There shall be a written agreement between the
  consumer and the PIHP/CMHSP delineating the
  responsibilities and authority of each party
• The agreement shall include a copy of the
  participants plan and individual budget
• The directions and assistance necessary for the
  participant to properly use the budget shall be
  provided to the consumer in writing when the
  agreement is finalized. (II-E-2)

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New B -3 OPTION Goods Services

• Goods and Services are available only to
  individuals participating in arrangements in
  self-determination whose Individual Budget is
  lodged with a fiscal intermediary. Projected
  savings from the use of the Individual Budget can
  be used to acquire goods and services that (1)
  increase independence, facilitate productivity,
  or promote community inclusion and (2) substitute
  for human assistance (such as personal care in
  the Medicaid State Plan and community living
  supports and other one-to-one support described
  in B3 Alternative Service definitions) to the
  extent that Individual Budget expenditures would
  otherwise be made for the human assistance.

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New B -3 OPTION Goods Services

• The purpose of the Goods and Services is to
  promote individual control over and flexible use
  of the individual budget by the individual using
  arrangements that support self-determination, to
  promote savings and the prudent use of Medicaid
  funds, and to facilitate creative use of funds to
  accomplish the goals identified in the individual
  plan of services through achieving better value
  or an improved outcome.
• A Goods and Services item must be identified
  using a person-centered planning process, meet
  medical necessity criteria, and documented in the
  individual plan of services. Goods and Services
  may not be used to acquire goods or services that
  are prohibited by federal or state laws or
  regulations.