Medicaid is the primary funding source for government services which treat people with severe mental illness, severe substance use disorder (SUD), and intellectual and developmental disabilities (I/DD), but it is not the only source. In Ottawa County, government programs that treat mental and behavioral health also receive funding through grants and the mental health millage.
Through Medicaid funding, dollars flow from the federal government, to the states, and into a sort of insurance holding account called a Prepaid Inpatient Health Plan (PIHP). In Michigan, there are ten PIHPs responsible for managing the Medicaid resources for behavioral health and I/DD services for Medicaid and Healthy Michigan Plan enrollees. These ten PIHPs each oversee payments to several counties. Lakeshore Regional Entity is the PIHP which distributes Medicaid dollars to Community Mental Health Ottawa County (CMHOC). The PIHPs are prepaid, meaning that CMHOC receives Medicaid funding based on the number of people in the county registered as eligible for these services, regardless of which services are provided.
This was explained during the April 24, 2023, CMHOC board meeting by Executive Director Lynne Doyle. “There will no doubt be a change in enrollment, and that’s important to us, [] because, our Medicaid rates are based on enrollment numbers in each county. So, if we lose people off Medicaid enrollment, our Medicaid rates will be impacted.”
When a person comes to CMHOC seeking services, an assessment is performed to determine if their symptoms are mild-to-moderate or moderate-to-severe. Those with mild-to-moderate symptoms are typically cared for through Medicaid Health Plans with community resources. Those with moderate-to-severe conditions are usually treated by CMHOC staff and the CMHOC provider network, but they have the option to self-direct their services. CMHOC is the largest provider of services for people with I/DD, severe mental illness, and substance use disorder (SUD) in Ottawa County. According to the April 24, 2023, board meeting packet, CMHOC receives over $49,000,000 per year in funding from state and Federal programs for mental health services. Of this funding, the vast majority is received for people with I/DD.
Source: April 24, 2023, board meeting packet
Source: April 24, 2023, board meeting packet
Ottawa County has about 568 adults with I/DD serviced by CMH, and approximately 101 are enrolled in the 1915(c) Habilation Support Waiver program which enables people to live in the least restrictive settings (and will be described shortly). Approximately half of the I/DD consumers are residing in adult foster care (AFC) homes (group homes). Of the approximately 101 I/DD adults enrolled in the 1915(c) Habilation Support Waiver in Ottawa County, roughly 25 are still living at home with family members or guardians. Legally, due to the Olmstead Decision, people with disabilities have the right to receive Federal funded supports and services in the home and community, rather than inside institutions, and this can usually be done for a fraction of the cost.
Some waiver programs for people who wish to use Community Living Supports (CLS) through the 1915(i) State Plan Amendment and 1915(c) Home and Community Based waiver programs are:
Children’s Home and Community Based Services Waiver (CWP) program
Serious Emotional Disturbance Home and Community-Based Services Waiver (SEDW)
Habilation Support Waiver program
More waiver programs in addition to mental waivers are described on the Medicaid site.
The Children’s Home and Community Based Services Waiver (CWP) program, for example, covers children under the age of 18. Under this a la carte program, a parent or legal guardian can hire providers which will be paid through a Choice Voucher System. Covered waiver services include the following:
coordinate services for community living supports (CLS)
enhanced transportation
environmental accessibility adaptions
family training
non-family training
fencing
financial management services
respite care
Through this program, depending on diagnosis, children are eligible for devices that can help them communicate, and can receive many alternative therapies including:
speech therapy
physical therapy
music therapy
art therapy
massage therapy
recreation therapy
Community living supports (CLS) includes providers that teach those with disabilities. Providers may work on how to handle household routines such as bathing and getting dressed. They can also serve as chaperones who enable the disabled person to better integrate into the community by teaching them to interact socially. Providers can bring a disabled child to places such as a playground, the movies, or grocery store where they might teach them how to purchase a ticket, or select food for snack time. Enhanced transportation and environmental accessibility adaptions involve custom modifications to the home or vehicle. All of the waiver services are designed to enable a family to provide accommodations to enable loved ones to continue living at home.
The MDHHS Behavioral Health and Developmental Disabilities Administration Inclusion Practice Guideline describes the policies and standards which govern all public mental health services. 1915(i) and 1915(c) Home and Community Based Waiver programs offer several self-directed service options, which facilitate people with disabilities living inclusively within the community. These waiver programs are described on the Community Mental Health Ottawa County webpage under contract service descriptions.
With such great options available for self-directed services, it begs the question: Why are so many Ottawa County residents with I/DD living in restricted adult foster care settings? It seems not only that these programs are difficult to navigate, but there may also be a financial conflict of interest which leads CMHOC to encourage consumers toward institutional living options rather than home and community based options.