Top Experts Answer CIL Questions About Contracts with Health Payers
Presented by Christina Mills, Amber OHaver, and Richard     
Petty
March 31, 2023

Richard Petty:// Welcome Christina and amber.  We regret that Rick Frederickson will not be able to join us today.  His son has been in an automobile accident and he's traveling to be with his son.  We're very concerned about his son, and have sent our concerns, and we hope a rapid recovery for Rick's son and for safe travels for Rick to be there to join his son.
Also, unfortunately, Paula McElwee who was one of our interviewers last week was not able to be with us today.  Paula had a death in her family.  Please keep Paula and her family in your thoughts over the next days.  Paula's mother passed away.
Let's begin today, and we have been and are still very excited about having this series of two webinars for you at Centers for Independent Living.  The possibility of health payer contracting for centers has great advantage for people with disabilities served by centers and for centers themselves.  People with disabilities can have access to services they would otherwise not have available, and the centers themselves can receive income from the work that is done through contracts.  That's resource development allowable activity as far as the operation of Centers for Independent Living is concerned.
Let's begin ‑‑ well, we're going to revisit some of the areas because there were more questions to be asked, and that were asked that we weren't able to get to all of the ‑‑ to be able to answer all of them.  We'll review some areas from the last webinar, delve into some topics more deeply, and we're eager to receive your questions.  You may place your questions in the chat, and either Sharon or Sandra from ILRU will voice them.  Or you can use the "raise hand" feature in Zoom and we'll open your mic so you can ask the question directly.
So we're eager to hear your questions so we can respond to them.  We have a panel today who have great expertise in both Centers for Independent living and in health payer contracting.  And Christina Mills and amber OHaver.  Let's begin by talking about the initial preparation for health payer contracting.  So to our panelists, here seems to be for many centers a gap between the initial concept of establishing a contract and really putting a contract in place.  Could you very briefly in a step‑by‑step fashion walk through the steps that a center needs to accomplish.  For example, I'll just say that they'll probably want to begin by reaching out to the state agencies that are responsible for organizing services through health payers in the state.  Those agencies will put specifications in place about which organizations can be contractors, and they may encourage the health payer organizations, the organizations that the states entrust with funds to do this kind of contracting work.  States can encourage them to use Centers for Independent Living.  What are some additional steps?  I'll put it out to both of our panel members.
>> Hi, Richard.  This is Christina.  Thank you for having Amber and I join you for this discussion.  I'm sorry to hear about Rick and his son.  I hope they're well.
Last time we talked a little bit about this, and I thought a little bit more about it since that first conversation, and I had to take myself back to what it was like when we were starting to figure out the process when I was us at the California Foundation for Independent Living Centers and ensure the centers for Independent Living In California had the opportunity to engage, if they wanted, in managed care contracts.  So to your point, even before the state agency conversation, figuring out who the managed care contract and providers will be for the state, I want to point out a couple of things.  One, you got to know your state's timeline.  Not every state is doing managed care contracts at the same time.  So you need to know what the cycle is, and when the next contract opportunity is coming up.  When those contracts come up, it's never a done deal that the same managed care organization is going to be awarded.  There's also ‑‑ depending on what state you're in, there could be multiple managed care contracts.  In some states, there's a large number of contractors.  In some states, it's a little bit smaller.  There's also specific contracts for specific populations.  So there might be a managed care contract that is the state is putting out to specifically serve people in managed care ‑‑ manage long‑term services and supports.  You'll need to know what is that entail?  What does that actually include in terms of the age of people that they're saying will be a part of this contract.  Will it be ‑‑ never assume it's going to be the 65 and up.  It could be lower.  We just saw Indiana take a different direction in how they put out their managed long‑term services and supports contract.  So knowing the information before you even get into the conversation with the state is really important.  I think the one thing that I forgot to say in the last conversation, when we were talking about this, was this is a long game.  This is not a short game.  So in addition to knowing the process and what the contract entails and the timeline, I would also say that you want to make sure that you're signed up for all the information where is going to be dispersed.  You want to make sure if there's stakeholder engagement opportunities, that you are there or if you have the capacity, organizing for other folks to be there within your network within your state.  Also, figuring out which managed care organizations are need to put in a bid.  Do you have relationships with those contractors?  Can you do a meet and greet and invite them to your center to get to know them.  Maybe the past contractors, if you don't know the new ones that might apply.
Also, just understanding what the state is going to be asking.  It won't necessarily be the same thing.  If it's a new contract, new contracts are always going to look different, of course.  If it's a contract that is coming up for renewal, it's likely that contract has some changes from the previous time, as well.  So making sure that you know that information front and back.
While you're doing that external work, internally I would really, really encourage centers and SILCs to look internally at what you do really well.  And how that fits into potentially contracting and partnering with a managed care and seeing whether or not that fits into what the state is requiring of the new contractors.
>> To get very detailed, what services are health payers likely to need CILs to provide?
>>  A lot of times, right now ‑‑ let's remember, I've only been here for a little over eight months.  I don't have as much experience as Rick does, by any means.  Care coordination is a definitely a topic of conversation.  Notice that I'm using Care Coordination language and not case management.  It's changing over time.  Language is an evolution.  I know for years Independent Living we said we don't want to use medical model language.  We don't do case management.  We're talking about care coordination centers that are in aging and disability resource connections and already doing case coordination.  You understand care coordination.  You understand what you can do and how you can maybe fold that into your ADRC work, as well.  Looking at peer‑support programs.  That's another one that is highly popular.  Transportation services, housing navigation, housing navigation and benefit navigation are also two really big ones, as well.
Also for SILCs and other organizations that don't do direct services, looking at ways to provide training for cultural competency of what it means to work and serve people with disabilities.  Making sure that you know disability language, disability etiquette, and making sure that if there's certain policies or programs for specific populations of folks with disabilities, like, whole‑person care, or self‑determination language to serve folks with intellectual developmental disabilities, that you know that stuff, and that you, also, are aware that there might be specific needs within those areas of expertise based on what the state puts in that contract.
>>  Great.
>>  Richard, this is Amber.
I think Christina did a fantastic job of going through the different pieces that need to be addressed and thought about prior even to starting having conversations about entering into a contract with the health payer of any kind.  So I think the take away, basically essentially relationship development is key with your state agency folks and your health payer folks.  Then any other fellow community‑based organizations and other partners that you have that can help leverage their relationships with the state agencies and those health payers who already may have existing contracts or existing partnerships in some way to help get your foot in the door, you know,  to speak.  So I think what is really cool, what is neat about starting anywhere from a year to two years, three years out, frankly, in a state, in advance of all the health payer type of contracting opportunities that may be coming to a state or there in terms of renewal opportunities of contracts is that as people with disabilities very rarely are we at these tables when the spokes at work and the contracts are drafted and developed.  Particularly the scopes of work, and what is cool in terms of what Indiana did when the SILC was at the table saying you need to ensure that the cultural competency work you're doing and your providers are doing is lead ‑‑ is developed by, lead by people with disabilities.   You know, you can work with other partners and vendors to do the work.  People with disabilities need to be at the helm in terms of development of that training and conducting that training.  In partnership with others, if necessary.  That's just when it comes to the cultural competency piece.  There's other tons of training, right, that can be done to health care payer staff and their providers.  Right.  Their vendors they utilize, and have sub contracts with.  There's all kinds of other opportunities for CILs.  To address social determinants of health‑related needs for the members or peers or Consumers with the health care agencies.  So Christina hit on a couple of those around housing, transportation, right, all of those pieces.  Who better?  We know as community‑based organizations, as people with disabilities, as individuals who know how to conduct and provide these core services in a way that supports us where we live, and the way we need.  It's really something unique and that no other entities in our state do.  Right.  Besides centers.  And SILCs, as well.  From an educational and outreach and awareness type of perspective and systems changework.  So any of the peer support and training, too.  So all of that is just sort of dig into that a little deeper.
>> And do you ‑‑ Amber, you brought up a term that emerged in the past few years that has become very important.  Social determinants of health or some say "social drivers of health."
>>  Yep.
>> Say more about that, please.
>> So, in terms of the contracts and what state ‑‑ so what we're seeing across the country is more and more of the contracts, these health payer contracts with states are requiring and expanding the types of social determinants of health related services that they provide in conjunction through their care coordination and service coordination type of services for their members who are peers and Consumers.  And that is because what they're realizing is as a state agency, and then, also, what health payers are, you know, obviously coming to terms with, and also recognizing is, if you don't have stable housing, your health is not going to be that great.  If you don't have access to transportation to get to and from medical points or doctor visits or to rehabilitation services or supports, your health is not going to be that great.  Ultimately, it will cost, right, the state and the health payer more money in the long run.  So let's address these contracts, these social determinant‑related needs for our Consumers, our peers to help stave off or prevent, right, unfortunate, like, health situations or issues, or to help prevent any of them from becoming exacerbated or, basically, getting, you know, keep them from getting worse.
>> And just to dig into that, that's really, really an important point, Amber.  The social drivers of health have to be Medicaid billable.  So you have to take that into account.  It can't just be, you know, I read a great care support program.  I think it should be what our managed care provider or health payer contracts with us for.  I was asking this question just earlier this week.  I was, like, so when do we get to decide whether we're going to partner with somebody to provide housing services versus not?  Like, where does housing come into this?  And I know everybody talks about housing.  It's one of the elephants in the room when it comes to needs for our community and for a lot of other communities.  And while housing is definitely a part of the social drivers of health, it's definitely there's, you know, lots of statistics around how housing keeps you healthier and well and living longer.  There has to be a track record of Medicaid says ‑‑ CMS says if you're going to ‑‑ if we're going to allow you to bill Medicaid for housing, we need it to be for folks that have ‑‑ let's say high visits to the emergency room.  They go to the emergency room frequently.  Therefore, if they had housing they may not do that because they have a place to stay that is safe and, you know, not in the weather.  Other reasons, as well.  If they're frequent fliers to the ER and you're saying housing is going to assist this person in staying more stable and decrease or eliminate almost their visits to the emergency room, then CMS will see that as a billable option under social driver of health contract.  But that may not work for everybody.  Right.  And Independent living Centers see folks who need housing for a variety of reasons.  You have to be careful.  You can't just think about, "okay, if I have the housing contract everybody fits under thatno.  It has to be folks that have a medical reason and, therefore, need housing services from you.  So I've seen centers get housing contracts with health payers because they're a Consumer and our peers might be trouble having navigating how to find a rental.  How to find an assessable rental.  Those seem to be contracts in need.  I've seen a lot of those.  Also, transportation services.  Folks needing to get to and from doctor's appointments, but I've been asking what about folks that need to go places beyond doctor's appointments?  I don't just want to go to the doctor's office.  Again, it's about social drivers of health.  And I learned this is very important to me.  Like, there's the medical transportation, but then there might be a different transportation contract that could be maybe a bundle transportation contract, which is hitting those social drivers of health that help keep that person healthy and stable through other interactions that transportation gets them to and from.
For example, the pharmacy.  For example, church or some other type of recreational activity that they participate in.  The grocery store.  There's other options.  So, you know, I bring those examples up because I think that it's okay to be creative.  One size does not fit all.  This is about having a conversation.  But it's also about knowing what you do and how you can build on that to do it even better and a healthier contract.
>> Great.  Before we move to the next slide, I believe we have at least one question in the chat.  Sandra, could you voice that question for us?
>>  Sure!  Sure.  We have a question in the Q and A, it's Veronica.  It says "what are the thoughts around providing the services through a single contract with community care hub instead of contracting individually with multiple plans?  ."
>>  Honestly, I haven't had that experience yet so I don't want to speak too much to it.  I can man how it would be helpful.  I think there would need to be a variety of MOUs in place.  And some pretty clear language on who is responsible for what.  And I say that personally just coming from a state where we've really pushed hard for aging and disability resource centers to be equal for Centers for Independent Living and areas for aging.  I want to make sure the same kind of equity and equality is happening in a community care hub.  I think community care hubs will be the next thing coming into play.  I don't think there's a ton of examples to share yet, though, on how they've been effective yet or not, in my experience.
>> Great.
Do we have any hands up?  Of people who want to voice their own question ?

>> >>: it looks we did for a moment.  Jane Johnson raised her hand.
>> Yeah.  We can unmute you.  Would you like to ask a question?
>>  All right.  I've unmuted Jane.
>> Thank you very much.  Yes, this is Jane Johnson.  I'm with Florida Association Centers for Independent Living.  We're a state association.  We've been working with some of the statewide managed care plans here.  We have a procurement coming up.  They haven't dropped the ITN yet but we expect it momentarily.  This is a really already this webinar has been so helpful.  Thank you for the information you're providing!  It's really spot on.  This is not the first time I've heard these speakers, but every time I listen, I learn something new.  I want to just, like, lift you up and say this is so valuable!
I had a question related to the question in the chat.  Instead of a community care hub, what if you had a, like, Centers for Independent Living in Florida we have varying levels of business acumen.  What do you think about trying to create a fiscal intermediary that would help do the medicaid billing and, you know, the interaction between the plan on the payment and the CILs so the CILs wouldn't have to set up their own internal operation.  Have you seen it work successfully in other states?  Sort of along the lines of better and directed care.   You know, those fiscal agents that the VA will pay for.  But not in Florida.
>> Yeah.
>> Yeah.
>> And, Amber, Christina, I believe Jane's question is going directly to network contracting.
>>  Yeah, Jane.  It's great to hear your voice!  And, you know, I used to be in your position in California.  I see at least one of our old ‑‑ one of my old member center directors here.  I haven't seen it happen with a managed care contract.  But Lindsay Miller, at the Association of New York.  I sort of copied her model.  She has the Association of New York has a money follows the person contract.  It's administratively it's run out of the Association.  And I really like that idea because I had always heard certainlies, you know, saying how rough it was to take on the administrative burden of some of these big contracts, or contracts that had a lot of complicated factors.  So we had done something similar in California when we started our display disaster access and resource program, which was funded and still is funded by one of the largest electricity companies in the United States.  Instead of them each contracting with Centers for independent Living, the association took on the burden of the administrative process.  It is a burden, I will say that.  But I think it helps a lot of the centers from adding on to the piece that they don't have.  The resources to do most often.  Depending on, again, their business acumen.  If you can do that and your centers are willing to do it.  I say it's a plus, plus.  I don't know if anyone would be able to speak to it as a center.  But in California when the Association took on the administrative burden for a state‑wide contract that we allowed centers to opt‑in or out of annually, based on the contract being annually, as well, it really helped.  And I could see that would be really fiscally responsible, too, for other states to do that for health payer contracts, as well.  Depending upon the level of work involved, of course.
>> Right.  I think on the back end of CILs, if you don't have the volume to support a separate billing person or the staff you need to do the work, then it really becomes ‑‑ it's not a workable business proposition.  But if admin costs can be claimed for intermediary and hire a bulling person and do it for the CIL, so they can handle referrals that come in two to three a month until the volume builds so it's predictable.  You can support having a dedicated FTE.  That's the biggest challenge we're finding.  Ramping up and developing the infrastructure without any funding guarantee is a real risk I wouldn't push any CIL to take on.
>> Yeah.  I would agree.   I mean, I'm being honest.  The program is amazing, but it's one of a kind, but it is an administrative monster.  I also saw it as a member benefit, and a way to grow and expand the centers to be able to do and show they can do even more in their communities.  And get other funding as a result of that.
I'm now hearing, though, just so you know and I don't know if it'll happen in Florida, I'm working a little in Florida, as you know, but I am hearing now that counties are interested in being the administrative hub.  I think there's some pros and cons to that.  So if an association can do it and has the capacity to make that happen, I think that's more in align with what the centers would need.
>> And, you know, we'll get to this later, but, Amber is there ‑‑
>>  Everything Christina said is spot on in terms of CIL associations.  I would say ultimately make the most sense is ones that arrive low coverage right to the state.  I know there are some states where the associations of CILs don't necessarily consistent of or all CLIs are not part of the association.  Right.  So they have health care contract and aren't a part of the association.  Right.  What happens in terms of the administration piece of things.  So what you can do in that case, or if you don't necessarily have a CIL association or not a strong one or one that consists of all of your certainlies or a majority of them is leverage your SILC.  Your SILC could, potentially, depending on the business acumen.  I would think three to five SILCs would be operating as a fiscal agent for the CIL or the CIL association.   You know, even ho thaw might contract and still, you know, want to utilize the SILC as a fiscal intermediary.  That's a great possibility.  And the SILC it helps to build and develop stronger relationships and, you know, partnerships with the SILC and with the CILs can learn and grow and do so together when it comes to taking advantage and being in the middle of, you know, being able to take advantage of these types of contracts moving forward.
>> What a great way to tie into the SPIL.
>> Absolutely.  Indeed.  We have some comments.  Let's move to the next slide, which is slide six.  We're going to begin here in a few moments to talk about internal preparation of your CIL.
But, Sandra, I believe we have comments.  Maybe not questions.  Could you voice those?  Then we'll move on into some more questions.
>> Sure.  So we had a thank you from Veronica.  We also have a comment from Fran Anderson saying billing is one of the functions of the community care hub.  The CCH manages all the administrative duties related to contract billing, reporting, contract compliance.  It makes it easier for the community‑based organizations participating and it gives the payers MCOs one entity to deal with to cover the entire state.
And Addie responded to, I think Christina's questions, he could speak to one of the points he was making.
Fran says we're doing this in Virginia.
Maya shared an article on improving health and well being through community care hubs.  That is in the chat.
>> And any other questions before we begin to talk about internal preparation?  Any hands up?
>>  Let me check the hands.  No hands up that I can see.  And no additional questions, at the moment.
>>  Okay.  This is Amber.  Can I make one small comment related to the community care hubs?
>>  Please do.
>> The one thing I would say, I think these idea and the use of these community care hubs is intriguing to me.  I think it's a way to leverage various types of strengths and experience in the state depending on the different entities involved in the community care hub.  But one piece I would say, not ‑‑ I'm not saying it's the caution or, you know, discourage everyone from utilizing those or considering those or getting involved in a community care hub, just trying to ensure, and you can do it in language through the MOUs or whatever type of partnership agreements you might have set up for the community care hub that the disability‑led directive voice doesn't get lost or pushed to the side.  Right.  In that space.  Because I think that's what is so often happens sometimes when we in Independent Living and the disabilities get involved and engaged in the various types of entities in our state, which is not a bad thing, I think, though, what tends to happen is sometimes we ‑‑ that disability lead and directed piece sometimes goes MIA.
Then you have to struggle with trying to get it back or you feel you're battling to have to explain why it's important and key piece of this.  So if you can somehow figure out how to build that into the language and maybe the value system within your community hub, community care hub, I think that would be, you know, important piece to make happen.
>> And, you know, earlier today we touched on creating opportunities for health payers to meet people with disabilities.  You received services from your organization and are, in other ways, connected with your organization.  And having that connection can be very valuable.  It can make a difference in how health payers perceive people with disabilities.
So here's a question that we touched on in our last webinar.  Let's revisit it.  It may need more attention.  What ‑‑ here this is capacity building.  What administrative skills will staff members of your CIL need as you prepare and conduct contracts with health payers?
 >> Well it's Christina.  A little bit of administrative but a little bit customer service, as well.  And I think there's even more to it than that in the early internal preparation.  But making, you know, doing any evaluation and looking maybe over a quarter and then the next quarter, however you time it out.  I would really encourage you to see what your follow up statistics look like.  Are you able to ‑‑ how fast do you call a Consumer back, if they leave a message?  How often ‑‑ what do the goals look like?  We're all familiar with independent living goals.  Are the goals being completed usually within a year?  Is it half a year?  A quarter.  All of those stats are really meaningful.  If you're not putting them into your annual report, which I'm assuming most of you probably are not, because it's so tedious and, yes, we have them in other reports, but that kind of information can be helpful.  And it can be a way to sell yourself.  In addition to that, so that's why I say it's a little bit of administrative.  A little bit of customer ‑‑ just customer service.  Plain, old traditional customer service.  Being able to call people back.  I hear endlessly people don't get calls back.  That's a difficult thing because a lot of times we know that folks don't have internet access or have digital literacy.  And the internet costs money.  So we're going to be using the phone a lot and we want to be able to prove we can make phone calls back.  And that the process for whatever assisting the consumer with is getting done.  We're meeting the goals.  I want to encourage you guys to think about what you publicly look like.  What is your social media have on it?  What are you pushing out?  And I'm always calling centers, like, some centers can tell you from the states I've been in so far, I just randomly reach out to centers because I'm looking at their websites and looking at their social media and thinking "what is this center up to?"
I'm paying attention to that as a health payer.  I think that's valuable information for all of you to know.  Make sure your websites are up to date.  Make sure it's appealing.  People want to look at it.  You're getting information from it.  And that your social media has some activity to it.  I don't really look at how many likes or followers you have.  But I'm looking at your content.  What do you care about?  What are you sharing with the community?  What is important to you.  I'm looking at all those things on all the different platforms to see what you're doing.
Then I'm reaching out and seeing, hey, want to have a conversation?  I want to learn more about what you're doing in the public emergency ‑‑ the end of the public emergency and how your community members are going to react to not having PPE anymore sent to them.  Whatever the case is.  But all of those public ways of communication externally are important.  Also, if you have ‑‑ it doesn't have to be lengthy.  I'm not looking for a novel or anything.  I actually would encourage you to look at things like Instagram and some small annual report examples.  But if you have annual report, putting that up on your website.  Putting that on social media.  I want to see that your ‑‑ you're engaged in the work you're doing through that report.  And you're actually putting it out because it's something that you're proud of.  And that you want other people to see you're doing at your agency.
And then, of course, if you can do any ‑‑ and I know this takes capacity and development and resources.  I completely get it.  If you have materials and alternative languages, if you can show that stuff and have it available.  If you're inviting a payer to come visit you, have those kinds of easy‑to‑understand and read materials ready to go and to give out.  Whether it's something you're going to hand me through the door.
>> And, you know, recording information on your website and your annual report about services provided.  Can also be a demonstration of your information technology skills.
>> Exactly.
>> And that is going to be valuable in contracting.
You also need service skills on the part of your staff.  Panel, help us think about the needed service skills and, also, about how the services that are provided to address social drivers of health.  How those track with IL core services.
>> Yeah.  And, amber, I would love for you to chime in here.  For me,  I mean, one of the things I'm looking at is depending on what your state ‑‑ what state you're in, does your staff speak multiple languages?  Do you put out materials in multiple languages?  And, you know, independent living I'm a very big believer.  No matter where I go Independent Living philosophy is in my heart and soul.  So I believe all the social drivers of health fall under core services.  It doesn't matter the way you look at it to me, they do.  I think as long as you're providing the core services well and you're able to show that and you are, again, putting that out to the world to see through some sort of report or infographic it shows you're proud of what you're doing and you have the skills to serve the people in your community.
What is hard to see when I see the bad reviews on Facebook of centers or I see bad reviews on Yelp of centers.   I mean, people say really harsh things.  Yes, they're not all true and some people just say it because that's the way they are.  I get that, but it's hard when there's a lot of them.  That is taken into consideration because you want to know how the community perceives your agency.  That's something that we're looking at when we're looking to partner with you.
The other thing is making sure that you have staff that with lived experience, of course.  So we might all be people with disabilities, but we don't always have the experience of walking the walk that our Consumers have walked or rolled.  And, so for me, one of the big things when I was doing benefit advocacies I was on SSI and Medicare in California for 24 years of my life.  There was nothing better than being able to sit down with somebody and talk to them about real‑life situations and being on SSI.  And what it was like to go into overpayment, and what I had to do to get out of that.  And how the IRS, you know, billed me the year after because I owed them.  And, oh, my gosh.  Like, it's great to be able to have people with real life lived experience, in addition to being disabled.  So that we know that we're contracting with folks that really get it and understand.  And don't necessarily, you know, I think there's a disability hierarchy, and sometimes if we're not seen as Consumers or had Consumer experiences, we may not be seen as peers.  That's a really important part of this work.
>> Great.
And, Sharon, let's move to slide eight.  Advantages to CILs have.  But before we delve into that, do we have any questions to voice?  Or any hands up?
>>  We do not.
>> Okay.  Well, we have heard from some of the listening sessions that we have had, and other interactions that the centers have experienced, in a strong sense, they are discounted by health payers.  That they are not thought to have skills or the capacity to do the work that health payers need to have done.
Whether it's true or not, how should CILs address this?  How do they go forward into this marketplace?
 >> Well this is Amber, Richard.  I would say it starts way in advance of even sitting down at the table to start and talking about contracting.  Right.  Between the CIL and a health payer or a CIL association or SILC or whoever the entity might be.  I think that it's important to remember that what is going to drive contracts is what is in the scope of work.  Right.  For these health payers, and the way to ensure that they are pushed in our direction is to have influence on that scope of work development piece.  And building into that language that talks about contracting with disabilities, what entities, you can even get specific.  Centers for Independent Living or the CIL or whatever the entities are that you feel strongly about in terms of the work that needs to be done through a sub contract, right, with these various melt payers.  So point number one, this starts, again, we've said it multiple times.  Like, way before, right, the RP even drops and is released.  Sometimes it starts as far back if there's an RFI opportunity, it's a great place to say you should be contracting with CILs.  You should be doing this.  You should be doing that.  And you can tell them what they shouldn't be doing and explaining and justifying why and what the benefit and advantages are and those are in responses to partnering and contracting or having those health payers contract and partner with the CILs and SILCs.  So all of that can be done in advance of that.  When it comes time for the, you know, RFPs dropped, proposals have health payers have been submitted to the state, they have selected and awarded the contracts outright.   You know, you kind of have a little bit of an idea just before that.  You may not have some kind of MOU or verbal agreement in place of the work we're going to do with one of the health payers.  So I think in terms of advantages CILs have in becoming contractors, I think, you know, Ma majority of are these at‑risk population‑based contracts.  And becoming more and more focused on, like, value and quality care outcomes, as opposed to just providing the service and here's how much you get paid.  They're centering payments and setting expectations in roles around, like, quality outcomes for the health payers in terms of servicing our peers with disabilities or their members.  And, you know, partnering with, like, a disability direction entity like a CIL and/or SILC offers unique and unparalleled approaches to providing our peers or Consumers with better, more comprehensive care.  It's very different than just, you know, what past years or decades of great health payer contracting has looked like in terms of the medical side of things.  So, I mean, ultimately the advantage is the CILs bring is life experience, right, that peer‑to‑peer automatic built in model of support and services, which ultimately, right, is going to increase the quality of life experience for their members, and it's going to drive down costs in the long run for the health payers.  So I think those are all key pieces.  The CILs bring to the table in becoming contractors.
Also, I like to remind the health payers and state agencies partnering with disability‑led and directed entities where the majority of those employees are people with disabilities, it's a very good equity‑based decision.  Right.  And it also is a way that you can even build in some of the ‑‑ build into the contracts with your health payers, you know, learning opportunities.  Training opportunities for actual staff in the CILs and help fund and support some of that to get them built up and get their, like, knowledge capacity right, strengthened or at a point to allow them to ramp up and be ready to do what they're expected to do for their contract for the health payers.
So all of ‑‑ I live by the motto, like, ‑is no.  And there's always room for negotiation.  Always.  So.
>> Great.  Really does any of this discussion have to do with the value of social determinants of health?  We would think that would be readily apparent to a health payer.  But does ‑‑ are those services the value of those services often discounted?  Are they left in other category relegated to CILs?  Does it leave CILs in a one‑down, one‑less position?
>>  You know, Richard, this is Christina.  I don't really see it that way.  I think that ‑‑
>>  Good.
>> I think as somebody who networks as a part of the payer system, but I also think it's about what do you look like to your community?  How does the community see you?  And if you're feeling that you're being discounted, where is that coming from?  Is there other perceptions out there that make you feel like you're discounted?  Because I'll tell you what, Independent living Centers are seen as another contributing potential partner with the bonus of having being led by people with disabilities.  It's the added bonus in that partnership of potential or potential contracts.  It's not seen as less than at all.  It's seen as great, let's partner with them.  But it's going to always come down to what is the quality of service, what do they do well?  What is the relationship look like?  And I feel like Amber and I could be completely broken records on this, but just like you would cultivate and develop a relationship with anybody else in your community, that has power that you want to work with, that you want to have a long‑term relationship with.  You've got to treat payers the same way.  It can't just be a one‑and‑done.  So relationship building, as we know, takes time.  It takes a lot of different ways that you can come at it sometimes.  If you don't know the payers in your community, or I'm not calling you or someone else isn't calling you, figure out who they're calling and have them do an intro!  We want to be connected but maybe we're unaffair.  Definitely, if you feel like you have what it takes and want to do this.  We want to talk.  It's a potential partnership.  Make sure you're examining internally what you do well, what you have to offer, what the state's requirements are, and how we can make it happen.
>> Christina, do you ever want to see evaluation data?  Do you want to see outcome information?
>>  Absolutely.
>> Do you ever want to connect with individuals who have been served to hear their stories?
>>  Absolutely.  I should have been more detailed about in in the annual reports or posts on social media.  However you're putting that information out.  Your Consumer stories, how many people you're serving, what kind of services you provided.  Making ‑‑ if you want to put together something that is specific to what you know your state contract says your managed care providers have to do.  We do care coordination, we do peer support.  You might not be using payer language, but it certainly, like I said, aligns with core services.  Figure out where is the line up and what are the outcomes and the success stories.  And have that information available.  Start distributing and marketing it.  Using it to your advantage.  Because it's not just going to be for a health payer.  It's going to be for anybody who has funding to give out.  Foundations love that stuff, too.  It's not just us.
>>  And this is Amber.  I kind of add two more things to that.  Something that I like to share and remind us all people with disabilities, you know, we are ‑‑ because we have to navigate the world very differently and figure out how to navigate the world differently and the environments we're in and the community we live in and places we live in or the places we reside.  The world is not built for us.  Right.  Programs and policies aren't really necessarily crafted with us in mind.  Or us centered or at the center of those all the time.  Right.  And so as a result, there's a lot of trauma and retriggering that happens for us as people with disabilities.  Because we're exposed to those barriers and attitudes and biases, right, on a daily basis most of the time.  A lot of us put it over to the side most of the time.  Because we have to get through our day, our week, month, year, whatever that is.  Right.  But I think it's important to also point out that, you know, peer‑to‑peer model of service, a person with a disability working with and supporting one of their fellow peers with disabilities, it really offers an unspoken level of trust and understanding.  Right.  That mitigates these potential triggers or retriggering and traumatizing types of experiences.  It cuts down on a lot of times the huge amount of emotional labor that has to happen.  Because there's stuff that doesn't have to be said between me and one of my fellow peers with disabilities.  There's just this understanding of you've got to navigate the system similar to I have.  I know you have similar types of lived experience.  It may look different.  There might be various types of intercepting identities at play in those relationships and dynamics, but at a base level, right, we're all fighting just to get through the day and navigate the world as best we can.  And if you don't want to talk about that and explain yourself a million times over, just the weight taken off your shoulder is huge.  So I think making that point.  Then, also, I think the other thing that we don't talk about enough is, like, we bring to the table us!  In all aspects, right, to health payers.  We're potential health payer members.  We are entities at centers and SILCs that can gather and exchange feedback and data on what barriers are happening in our state as far as disability related issues or needs.  The health payer having that information is going to be able to craft a proposal or response right back to the state in the manner that will help address that recognizes and helps to address some of those related, you know, disability needs in our state and communities.  And that's also something we bring to the table.  A lot of other ‑‑ at a level that a lot of other entities don't have and can't provide.
>> And that's great!  And, you know, right now we're talking about how to influence health payer perceptions about Centers for Independent Living.  Imagine framing this as an advocacy agenda.
>> I was going to add, too, Richard.  Amber, I couldn't have said it better.  Thank you.  And that table that she's talking about, whether you know it exists in your community or not, but getting to the existing or any health payers' advisory committee, their board meetings.  Getting on their agenda to do a presentation about your CIL.  Like, if it's the long game, think of the ways you can just participate as member of the public at the meetings they're already holding.  They get used to seeing you.  Asking, eventually, if you can get on the agenda to talk about what your organization does.  Those are all steps in the right direction.
>>  Right.  And do we have any chat questions?  Any hands raised?
>>  I am checking right now.  It does not appear that we have any new ‑‑
>>  Okay.  Okay.  You have questions?  We have answers!
We'll keep moving ahead, but we're eager to hear and address your questions.
This is a rare opportunity to have these folks in the same Zoom room together with you.  Let's move on to slide ‑‑ I believe slide nine.  That's operator contracts.  Sharon, am I tracking that correctly with you?  Operating are under contracts.
>>  Yes, that's right.
>> Well and we talked a little bit about certification requirements.  Christina, what certifications do you as a payer need to see on the part of centers that contract with you?
>>  You know that's a good question and it depends on the type of contract and what state you're in.  The state has different requirements.  I think what we've seen that is really important, and, again, goes back to really being invested in connected in your community.  Regardless of if you have the certification required or not.  Do you have a partnership with another community‑based organization that does have the certification that you can partner with?  And I bring this up because I've seen many times people say, oh, I can't do this because our CIL doesn't have a social worker.  Doesn't have the MFT.  Maybe your organization doesn't, but does one of your partnering organizations that you already do work with have that?  Are they willing to partner with you to ensure that you reach that certification requirement?  Thinking creatively, I think, is an important part of this work.  We're not trying to make people do more or, you know, put in more resources to be able to do the contract work that is needed.  So I've seen that over and over again.  Centers feel left out because they don't have the certification requirements.  But I think there's definitely ways to get past it thinking creatively and about what other folks should work with that might have it.
Also, just going back.  What did your state require?  When they were coming up with the requirements, were you a part of the stakeholder process that talked about how that would put your organization out of the opportunity?  Out of line of being able to contract?  So, again, it's ‑‑ it goes back to those early, early discussions and making sure that you're a part of the process, so you don't get written out of the process.
>> Great.
>> This is Amber.  An example of that is in yawn.  When they drafted the initial draft of, like, the RFP and released them experts over that.  Their Care Coordination and Service Coordination had requirements.  You had to be a registered nurse.  Or you had to have a Master's Degree in social work, and these various types of requirements when the reality of it is, explain to me why.  Why is that necessary?  Why, you know, Centers for Independent Living and those of us involved in Independent Living, right, can provide care accord nation and service coordination and not be a nurse and not be a social worker.  Right.  And bring all of these key components of our lived experiences and expertise.  Professional and personal level to the table without having to be certified of anything.  Or for anything.  So I also would like to encourage folks to push back against their states that say, no, you need to be a social worker or you need to be a nurse or you need to have this type of right certification or expertise to do some of this work.  It's just false.  It's harmful, frankly.  And to really say that, you know, in recognize that Independent living is about deprofessionallizing, demedicallizing the world and the systems we have to learn how to navigate and live with on a day‑to‑day basis.  Because we really need ‑‑ if we're talking about truly providing, like, comprehensive care, whole‑person care, we can't continue to operate, right, and expect and require the same kind of certifications or, you know, other types of expertise in a manner that continues to create massive levels of barriers and harm various individuals from having access to folks who could actually support them in the way they need and want to be supported.
>> Am I hearing ask why and pushback?  And advocate, advocate, advocate for your center?
>>  Yes.  Yes, you are.  Exactly what I'm saying!  Yes.
>> And so now this is ‑‑ oh.  Let's ‑‑ it looks like a comment from Jane.  Jane, would you care to voice that?  We can arrange that.
>>  Okay.  I have unmuted Jane, if she would like to voice it.
>> Thank you.  Yeah.  I'll go ahead and read it as I wrote it.  You were talking about provider qualifications.  We were struggling with that, also.  Because most of our CILs don't have licensed and certified staff that are doing very qualified work, and when I was researching the medicaid handbooks, I found the CILs have been listed as Medicaid providers in the days before we rolled everything to managed care.  The basis for their qualifications was because they're mentioned in statutes.  So it said per chapter 413, blah, blah, centers for independent living are qualified as providers and listed the different ‑‑ it was a matrix of the different services they are qualified to provide services for in Florida already.  When I showed that to the managed care plans, were unaware.  I stumbled upon it.  So there may be states where CILs were providing services before managed care and you might be able to slip through, you know, looking at some old regulations.  I know that medicaid provider handbooks are hard to update because they have to go through the rule‑making process and plug notice and all of that.  A lot of times agencies don't like to open up that stuff unless they have to.  Because then folks will try to make lots of changes they don't want.
But anyway.  That was a nice thing we still would have to enroll in Medicaid but there's, like, aless stringent version of a Medicaid provider setter they indication the CILs would qualify.  They already have status in the handbooks.
>> That's a near‑perfect from the voice of experience heads up to all of us!  That's a great example.  Thank you, Jane.
>> This is Amber.  If you can get around the language or the state, health payers are locked into insuring their contract with providers to provide Medicaid,‑related services to those contracts.  Talk to them about actually contracting out as a value‑added service you bring to the table outside of the role of Medicaid.  I see that happen a lot of ways.  Not just with health payers we're talking about today but with a lot of other types of entities and a lot of types other programs and services.  Right.  That are out there in states and communities.
>> And we are doing that, Amber, with a plan in Florida now.  We're working through the process of rolling out a proposal for transition services.  But it would not be Medicaid.  It would be outside of Medicaid.  But ultimately the CILs want to be on the same state with all the other providers to provide those social determinants.  But doing it outside of the official system does ‑‑ we will be ‑‑ it doesn't eliminate some of the hurdles that setting up yourself for Medicaid billing and all of that.  There are advantages but long‑term we want to see the CILs on equal footing.
>> Yeah.  Keep pushing your state, Jane!  Keep pushing!  Keep pushing!  I have a feeling you'll get there!
>>  Yeah.
And I bet this is on the tip of someone's tongue.  You have you're a CIL.  You have a relationship with a health payer, you have a contract that is in place, and uh‑oh, you're not getting referrals, and sometimes even when you get the referrals, you don't get payments on a very timely basis.  What do you do?
>>  That's a really good question!
[ Laughter ]
As Amber nods her head.  So I think that's actually a really good and important prep question, Richard.  So as a center or association or CIL is looking to enter into that contracting process, asking what is the reimbursement or what is the payment process look like?  That's really important.  Because we all have different systems, and some of them can take longer than others.  Some of them are becoming very digitalized, and can be within 24 hours in some cases.  So having that information and knowing up front is really important.  When it comes to the billing part of it.  Now in terms of the referrals, I think that's also really important to discuss in advance.  And setting up to make sure that you're going to be paid even if a certain number of minimum referrals come in is something that you need to think about.  Because this is a business opportunity.  This is a contract.  And you're setting up your business to be able to deliver on that contract.  Therefore, you're expected to be paid for it.
>>  Wow.
>> That's where front loading your contract with funds, I think, is helpful.  Starting to ramp up transitioning into starting to begin to provide services to kind of work out any kinks and get capacity level where it needs to be, right, to start addressing, you know, provided services and things like that that are you're going to be tasked to do.  I think the other thing to remember is to Christina's point, too, what does the payment model look like?  And having those conversations.  Is it a population‑based payment model?  Value‑based payment model?  What does value mean.  You center to define it and lay it out, right, in terms of, you know, if we do this, this, and this.  It shows the value we've provided.  We get paid for that.  What does it mean?  What does it look like?  And really dig into that side of things.  It goes back to it's helpful sometimes.  You have a current relationship with an attorney or lawyer that does ‑‑ has experience or background in contracting negotiation and things like that that can come in handy.  Someone that serves on the SILC.  Maybe an attorney that has that kind of background.  Think about bringing in some of these various types of legal contracting experts, too, to help you navigate this, as well.
>> One of the things that I will say, and a reason why I gave that answer, too.  I had no idea how different payers were, but, also, how different contracts looked from center to center until I was in this position.  I have to say, hats off to some of the centers that have come up with some very creative ways to make sure that they get paid for the work they're doing.  Or the work that they expected to do but aren't getting the referrals they thought they would be getting.  So that really is just come from what I've learned.  I would, with that said, if you know centers that are contracting with, especially different payers, I would encourage you to call and interview them and talk through these things with them, as well.  Because I think that, you know, there's lessons to be learned from your peers, our peers.  But, also, just knowing as much information early on as possible.  Some of the tips and tricks that you can get from learning how they have done their work.
>> Can you give some examples of the tips and tricks?
>>  I think Florida's got some good examples of ways they put in some minimums so they get paid regardless of the number of referrals that come in.  That was one of the centers that I was, like, wow, that was really a good idea.
Then I've seen some centers that maybe thought that there wasn't room to negotiate the contract or thought that they needed to just take what was given to them as an opportunity and ended up with the contract that really became an administrative burden.  Theaz ‑‑ these are with different payers.  I'm saying you want to talk to those who have done it.  You want to talk about the length of the contract, how long have they been doing it?  What was the ramp up time?  Was ramp up taken into consideration?  What has been ‑‑ what has the payment method or payment reimbursement model looked like for centers?  I think that if you can do a contract that allows you to have some upfront funding and then reimburse based on work, that make help a center out a little bit more.  Or a SILC or an association, if you can navigate that discussion and put it into the contract.  That is always going to be helpful.  Making sure that, you know, the services that you do well, that you want to contract for can be billed through Medicaid is going to be important.  And even if I haven't thought about how they can be billed through Medicaid, maybe you've thought of a creative way of why peer support should be offered to a certain population.  And you can tell me how Medicaid is going to fund it.  Because it's going to result in people going to the emergency room less.  Things like that.
>>  Okay.
>>  Richard, if I may.  This is Amber.  Think of how you can even get access to chunks of funding as sponsorships or supporting programs.  Right.  And initiatives that the health payers can pay as supporters or sponsors.  That doesn't necessarily require a need or contract or it may not be, like, long‑term base funding but it gives you a nice pot chunk of funds up front.   You know, to do a project or initiative or to run a pilot of some kind.  Right.  And support that.  It might be outside of, like, a long‑term type of contract here.  So just, you know, I know in Indiana, when we were going through things, we talked with various, you know, health care payers.  That was some of the stuff that we talked about doing outside of a contract as a SILC, and I've seen other states do that, as well.  And a few different ways.  So leverage both opportunities!  Don't be afraid to ask.  Because it might be something that is more advantageous for not only your center or centers and your SILC and the health payer, too.  It depends on the situation and scenario.
>> Wonderful.
Sharon, as always, is on top of our time.  So we have a couple of options.  We can ‑‑ we could talk more about networked contracts, or we can talk about the role of SILCs, or we can answer other questions you may have.  We're not set up for a poll today, but if you don't mind, just say if you can put a note in the chat very quickly and let us know which of the three things I've mentioned.  Networks, SILCs, or other you would like us to address.
>>  This is Amber.  Can I throw out a question to the attendees?
>>  Please do!
>>  Okay.  I would love to hear from anyone if they want to share if you're in discussions with health payers right now for contracting?  Are you in the thick of locking one down?  If so, are you running into any barriers or what things are going really well in that process.  I would be curious to know how many folks are in the thick of it now.  It sounds like we have a couple of various folks that have contracts in place.  So I just would love to know more about what you guys are experiencing out there in your states.
>>  I think it was a great idea.  It might be where great for all of us to hear your responses.  May we do that?
>>  So can you break down the question a little bit?  So we might take in pieces.
>> Are you asking me that question?  This is Amber.
>> I am.
>> I'm so sorry.  I'm having a hard time hearing you.
>> Can you break that question down?
>>  Uh‑huh.
>> Maybe if it's ‑‑ maybe if we do it in a few pieces.
>>  Sure.  Maybe ‑‑ let me start with, is anybody currently negotiating a contract with a health payer right now?  Or been approached by a health payer to do work in that way?  I got one no.  Anybody else?
>>   ‑‑ says no.
>> And I think, Richard, we lost Christina.  I think her internet dropped out.
>> I'm back.  Hopefully.
>> There she is.  YAY.  I don't know if you want to elaborate or break it down further.  The question I asked.  Were you on here when I asked.
>> Is there anybody currently in negotiations for a contract?
>>  Yeah.
>> Yeah.
>>  Yes.
>>  You're so right.  I regret that we scheduled for that day.  I'm very sorry about that.
>>  This is Jane in Florida.  We're working currently with two health plans on different types of contracts.  Both of them are outside, you know, regular medicaid, but they are our noses are getting under the tents.
>> This is Amber, that's awesome, Jane!  Do you feel those are going well?
>>  They are going really well.  Yeah.  And, of course you know, Florida is a procurement is just about to happen.  So before that, I have let with the state agency for, you know, that has been released the contracts and let them know, you know, some of the things we would like the CILs to be able to provide and the extent possible to get that written into the contracts.  So there's an incentive for the plans to partner with us.  Is the money piece is going to be the trick, I think, because, you know, for all the reasons you cited.  I can't thank you enough for this conversation, again.  It's so instructive!  Even though we're far down the road.  There's so many variables that I want to make sure that we understand before the CILs take a financial risk.  We'll see.  The rumor is it will drop next Friday.  I don't know if it's true or not.  It's a $38 billion ‑‑ it's a lot of money that Florida will spend on Medicaid managed care.  We expect a lot of activity.
>>  And great point.  You're an emerging ADRC and being asked about your contracting plans.  That's ‑‑ and that's great, Eddie.  I hadn't expected that.  It's great to read that.
>>  Eddie, remind me for Humbolt and your other counties, Trinity and such, who is the managed care provider up there?  You can write it in the chat.  The one thing that is, you know, happening in California right now is all of the in lieu of service contracts.  There's creative ways to figure out how to provide services through our Medicaid Cal aim process.  And we stayed in California with the 1115 waiver.  I was thinking if I was at the association, Jane, it might help, too.  If I was at the association, I think it would be time for us to take on the Medicaid biller.  Because when there was an analysis done at one of the California centers to see if it would be cost effective to go into a Cal AIM contract, it looked as though there would be a loss because of the administrative burden.  So to Jane's point, that's why I was thinking it's time for somebody to take that responsibility on.  So the centers can do the good work they do.
>>  Okay.  We have another statement in the chat.
>>  Alexander said no contract with us.  We do NHTD/TDI waiver.
>> I'm assuming that's nursing home transition and diversion?  Okay.  Okay.  Yeah.  Yeah!  I figured out the acronym!
>>  Yes.
>> Thanks, Sandra.
>> That's good!
>>  Cool.
>> I'm always impressed when people can quickly identify an acronym.  That's good.
>> And the nursing home transition and diversion what a way to sell yourself.  You guys are doing that really well, like, hey, your members that are currently institutionalized, we can help work with them to get them back into the community.  Guess what that is going to do?  Cost you a lot less money to have to serve them and support them through your health plan.   I mean you know, not everyone that is necessarily the case, but, I mean, it's definitely a huge selling point.  It's one of the things, I think, that I know I have been pushing for in Indiana, but then elsewhere, too.  Like, you know, we're federally mandated to do that work as centers.  Right.  Pay us for it!  We're really good at it!
>>  And I'm seeing a comment about plans constantly ‑‑ consistently wanting to lower hours.  What do you do about that panel?
>>  I'm looking for that comment.  Sandra, can you voice that?  Maybe I misread it.
>>  I don't see that comment.  I see a comment from Susan in Nassau county, New York.  Several contracts with managed care plans for the past 12 years plus, these are fiscal intermediary contracts for CDPAP.  We find the plans to be very uncooperative in negotiating and only interested in cutting consumer hours so they can make additional revenue.  Nonetheless, we are interested in doing training and cultural competency in other areas that the plans need help with.  And are having a hard time finding the right contact for within the different plans.
>>  That's the question.
>> okay.
>>  This may be a great way to leverage any relationships you have with your state agency peeps.  Let them know, like, the challenges you're experiencing.  Not to tattle, but say, hey, like, here is the benefit to what we do and what we are doing.  How can you help us navigate some communication in this area?  And related to these kind of issues that we're experiencing.  I don't know if it's a possibility.  But there tends to be some of those.  Christina can probably speak more to this.  I believe there are, depending on the various contracts in place, different types of liaisons, right, for providers.  If I'm not mistaken ‑‑ at least I know in some RFPs I looked at had to have different kind of, like, provider liaisons or provider folks that can help navigate these kind of barriers with their provider sub contractors.
>> Yeah.  And, you know, I misspoke.  That wasn't a question but it was a comment that did spark a question.
>> Yeah.
>> In me.  And, again, this seems like an advocacy issue.  You as advocates for the people that need the services and as advocates for your own soundness as an organization providing services.  So once again, we've come to an end.  We do end on time to make sure that we meet the needs of our interpreter arrangements and our captioning arrangements.
We're doing captioning for this webinar.  So, panel, it is a great pleasure to be able to learn from you!  We're grateful for your time and your expertise.  I hope we can work together again soon to do more answers and more webinars, and members of our audience, our participants on this webinar, if there are things you want addressed specifically, send us cards and letters in!  We'd love to hear from you!  Send us e‑mails or communicate with us on social media.  However you'd like to.  We would be eager to hear from you.
So everyone, be safe!  Be well.  Thank you very much.
>> Richard, this is Amber.  Can I make one comment?
>>  Recording stopped.
>> Yes.
>> Just make sure one of the things you can do that, you know, I wouldn't be below doing is e‑mailing the health plan President for the state in your state.  Right.  That health plan and/or the vice president.  Then CC the state.  Or some of your leadership in your state or whoever is, like, over the health plans.  Right.  Through the state agency in your state.  See if you get some communication response back then.
>> Great.  Great.  I think we're about to lose captioning.  But, again, wonderful presentations from Christina and Amber.  Thank you so much!
>>  Thank you.  Have a wonderful weekend.
>>  Thanks!
>>  Aloha, Amber.
>> Oh, yes.