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BlueCare Tennessee and BlueCare, Independent Licensees of BlueCross BlueShield Association

Employment and Community First

(ECF) CHOICES Overview

Virginia Piper RN CCM CDDN

ECF CHOICES, Consumer Advocate E TN

To provide a brief overview of:

Definition of Medicaid Waivers

The mission and goals of ECF CHOICES

ECF CHOICES Eligibility requirements

ECF CHOICES Groups

Referral process

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Objectives

Prior to 1981, Medicaid funds

were only allowed to be used for institutional programs such as state-run facilities like Arlington Developmental Center, a hospital or ICF/ID (previously referred to as ICF/MR).

The federal government

reimbursed the states 50

percent of the costs of these

institutions.

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What’s a Waiver? Pulling it all Together

Community movement

Federal regulations changed

States could ask for waivers to allow the Medicaid funds to be spent on services outside of institutions in homes and other community based settings

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What happened in 1981?

Services only available for Tennesseans with ID-not DD

DIDD Waiting List > 6000 people

Only “Crisis” enrollments

Spending twice national average per person per capita for ID services

Higher % of people using 24/7 residential services than other states

Natural supports supplanted in 24/7 service model

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DIDD Waiver

“Tennessee proposes to become the first state in the country to develop and implement an HCBS program that is specifically geared toward promoting and supporting integrated, competitive employment and independent living as the first and preferred option for all individuals with intellectual and developmental disabilities: Employment and Community First CHOICES”

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Origin of ECF CHOICES

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After much discussion between the State of TN and Stakeholders, the Centers for Medicare and Medicaid (CMS) approved ECF CHOICES program in February 2016.

July 1, 2016 ECF CHOICES went live.

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Fast Forward to 2016

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Mission and Goals of ECF

Mission and Goals of ECF CHOICES

Integrated HCBS services program

Aligning incentives toward promoting competitive employment

Aligning incentives toward supporting integration

Competitive employment and independent living as the first and preferred option

Provide services for adults with ID and DD

Supports for families caring for a person with I/DD

Consumer-Direction Options

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ECF CHOICES Program Benefits

• Integrated physical/behavioral/Home & Community

Based Services approach

– Preventive support services to avoid crisis

– With competitive employment and independent community

living options

– Less restrictive, with more independent community living

options

– Smaller, capped benefits to serve more people

• Launch July 1 with ~1,700 members, two MCOs

• New Network Providers – Employment and Housing

• MCO Advisory Groups to collaborate with advocates

statewide

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Employment and Community First (ECF) CHOICES

Who is Employment and Community First CHOICES for?

Tennesseans with Intellectual Disabilities

Tennesseans with other Developmental Disabilities

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Intellectual Disability

Defined as substantial limitations in functioning:

IQ 70 or below that exists concurrently with related limitations in two (2) or more of the following adaptive skill areas: communication, self-care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure, and work; and

That are manifested before eighteen (18) years of age.

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Developmental Disability

Developmental disability in a person up to five (5) years of age means a condition of substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in developmental disability as defined for persons over five (5) years of age if services and supports are not provided

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Developmental Disability

Developmental disability in a person over five (5) years of age means a condition that:

As attributable to a mental or physical impairment or combination of mental and physical impairments;

Manifested before twenty-two (22) years of age;

Is likely to continue indefinitely;

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Developmental Disability

Results in substantial functional limitations in three (3) or more of the following major life activities:

(a) Self-care; (b) Receptive and expressive language; (c) Learning;(d) Mobility;(e) Self- direction;(f) Capacity for independent living; or (g) Economic self-sufficiency; and

Reflects the person's need for a combination and sequence of special interdisciplinary or generic services, supports, or other assistance that is likely to continue indefinitely and need to be individually planned and coordinated.

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Developmental Disability

Some common developmental disability diagnosis

Cerebral Palsy

Autism

AD/HD

Hearing Loss

Vision Impairment

Fragile X Syndrome

Fetal Alcohol Syndrome

Intellectual Disability

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ECF CHOICES

Groups

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Employment and Community First Groups

Three benefit groups

Essential Family Supports (Group 4)

Essential Supports for Employment and Community Living (Group 5)

Comprehensive Supports for Employment and Community Living (Group 6)

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Essential Family Supports (Group 4)

Families with children under 21 with ID or DD Adults age 21 and older living at home with family

caregivers may also elect to enroll in this group Meet NF LOC or without HCBS, “at risk” of

institutionalization HCBS beyond scope of early and periodic screening,

diagnosis and treatment (EPSDT) that will help support families and sustain natural caregiving networks

Help plan and prepare for transition into employment and integrated, independent living in adulthood

Hope to serve up to 500 individuals in this group in year one, subject to appropriations

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Essential Support for Employment and Independent Living (Group 5) Adults age 21 and older with ID or DD Without HCBS, “at risk” of institutionalization Helping adults plan and achieve employment and

independent living goals and experience community life Assisting young adults to transition from school into

integrated, competitive employment Hope to serve up to 1,000 individuals in this group in

year one, subject to appropriations Prioritize for enrollment young adults transitioning from

school who are already employed in an integrated setting

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Comprehensive Supports for Employment and Community Living (Group 6) Adults age 21 and older with ID or DD

Meet NF LOC and require specialized supports related to I/DD (more significant needs)

More intensive level of services/supports

Help adults plan and achieve employment and community living goals, become as independent as possible, participate fully in community life

Hope to serve up to 200 individuals in this group in year one, subject to appropriations

Prioritize for enrollment families with aging caregivers

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ECF CHOICES expenditure caps

Essential Family Supports (Group 4)

$15,000 (not counting the cost of minor home modifications)

Essential Supports for Employment and Independent Living (Group 5)

$30,000

Exception for emergency needs up to $6,000 per year (hard cap of $36,000); consistent with Self-Determination Waiver

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ECF CHOICES Expenditure Cap, cont

Comprehensive Supports for Employment and Community Living (Group 6)

$45,000 (low to moderate need)

$60,000 (high need)

Exception

Up to applicable average cost of NF + specialized services for DD with exceptional medical/behavioral needs

Up to average cost of private ICF/IID for ID with exceptional medical/behavioral needs

Level of need, including exceptional medical/behavioral needs, to be determined through use of the Supports Intensity Scale, administered by an objective entity

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Enrollment Targets for ECF CHOICES

Enrollment for Year 1 ECF CHOICES for ALL MCOs

Year 1 - July 1, 2016 – June 30, 2017

Essential Family Supports – 500 people

Essential Supports for Employment and Independent Living – 1000 people

Comprehensive Supports for Employment and Community Living – 200 people

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Enrollment Criteria

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Priority Categories

Three Groupings:

1. Employment category (1-6)

2. Individuals with aging caregivers

3. Individuals in an emergent situation

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PRIORITY CATERGORY Employment

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1. Any age applicant that is CURRENTLY employed and needs supports to maintain

employment

2. Applicants 18-22 y/o transitioning from school who are

employed OR have a commitment from

employer

3. Any age, recently unemployed and in need of supports to

obtain and/or maintain new employment

4. 18-22 years old transitioning from

school with expressed desire for employment

5. Unemployed with desire and

commitment to work

6. Transition age youth in Group 4 planning for employment supports not available through

IDEA or VR

Enrollment Prioritization Criteria

Individual with Aging Caregiver

According to State law: aging caregiver is defined as 75 years or older

Reserved number of “slots” will be establish to enroll eligible individuals

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Enrollment Prioritization Criteria

Individual in an Emergent Situation

Loss of primary caregiver

Evidence of serious abuse, neglect or exploitation

Facilitate transition out of a NF or ICF/IID

Age 21 or older in group 4 or 5 through a safety determination must be transitioned to group 6

Danger to self or others

(Requests for enrollment into a reserved emergent slot will be subject to critical review by TennCare/DIDD interagency review committee)

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ECF CHOICES

Services

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Supported Employment There are 15 individual supported employment

services available in ECF CHOICES.

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Employment and Community First CHOICES

ECF CHOICES Supported Employment Services are designed to:

Meet people where they are in a career path

Unsure about employment

Unsure of employment options

Wanting to “try” a job to learn more

Needing paid support OJT

Provided on an individual basis

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Employment and Community First CHOICES

Employment is defined by the following

Competitive – a job that any one can apply for, with or without a disability

Wage must be at minimum wage or above

Integrated setting

Level of benefits paid by employer for same or similar work

CANNOT be provided in a “facility-based” setting

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Employment and Community First CHOICES

ECF CHOICES Supported Employment Services are designed to:

Support people in self-employment

Self-employment start-up plan

Help to explore sources of business financing

Payment to provider for Supported Employment Services are outcome based

Service provider must produce written report summarizing the process and outcomes of the service

Report contain recommendations for next steps in career path

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Employment and Community First CHOICES

Individualized employment in an integrated setting either:

Sustained paid employment in a competitive or customized job

Sustained paid self-employment that is home-based or conducted in integrated settings

Net income in relation to hours worked is no less than minimum wage

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ECF CHOICES Benefit Chart

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ECF CHOICES Benefit Chart, cont.

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ECF CHOICES Benefit Chart, cont.

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ECF CHOICES Benefit Chart, cont.

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ECF CHOICES Benefit Chart, cont.

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ECF CHOICES Benefit Chart, cont.

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ECF CHOICES Benefit Chart, cont.

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ECF CHOICES Benefit Chart, cont.

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ECF CHOICES Benefit Chart, cont.

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ECF CHOICES Benefit Chart, cont.

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Employment

Prior to using any ECF Employment Services, all Vocational

Rehabilitation benefits MUST be exhausted.

**We are still waiting on the Memorandum of Understanding between Vocational Rehab and

TennCare to see how this gets defined and operationalized.

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How We Get Our Members

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How we get ECF CHOICES members?

On July 1, 2016:

DIDD waivers closed July 1, 2016 (no new enrollees, except those in DCS custody who are eligible will be enrolled in the DIDD Waiver until January)

Individuals on the DIDD waiting list received a letter of notification from TennCare

Letter describes ECF CHOICES and online self-screening process

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On-Line Self Screening Referral

TennCare Self-Screening Tool:

On-line application to collect basic information to assist in determining the applicant’s likelihood for meeting target criteria and priority enrollment categories

Applicants who need assistance or who do not utilize the self-screening tool, a telephonic screening will be conducted utilizing the same electronic tool

https://tcreq.tn.gov/tmtrack/ecf/index.htm

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Intake

For applicants who are currently enrolled in Medicaid and are Amerigroup or Blue Care members, their MCO will conduct intake

For applicants who are not currently enrolled in Medicaid OR who are currently enrolled with United Healthcare, DIDD will conduct intake

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Financial Eligibility

The following financial criteria must be met:

Resources must not be more than $2,000

Individual Monthly Income must not be more than $2,199

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Referral List

Referrals sent by TennCare who are not enrolled have an option to remain on the referral list

If they choose not to remain on referral list, signature must be obtained

People on the referral list will be contacted via phone annually by Population Health case management

Change in circumstances that might lead to enrollment will be reported back to support coordination to process

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Transformation and Hope

• This program is about transforming the current

system

– More meaningful

– More focused on the whole person

– More appropriate services and support for individuals with

intellectual and other developmental disabilities

• This will bring HOPE to these individuals and their

families in a way they have never known before

We are about to change lives!

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© 2016 BlueCare Tennessee Proprietary and Confidential