Sandhills Center 1915 (b)(c) Medicaid Waiver Implementation

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Sandhills Center 1915 (b)(c) Medicaid Waiver
Implementation

• Presented by
• Sandhills Center

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What is a 1915 (b)(c) Medicaid Waiver?

• A combination of two sections of the federal
  Social Security (Medicaid) Act.
• Section 1915(b) is called the Managed
  Care/Freedom of Choice section
• This Section provides the US Health and Human
  Services Secretary authority to grant waivers
  that allow states to implement managed care
  delivery systems, or in other words, limit choice
  of providers under Medicaid.
• Section 1915(c) defines a set of waivers called
  Home and Community-Based Services.
• This section provides the Secretary the authority
  to waive Medicaid provisions in order to allow
  long-term institutional care services to be
  delivered in community settings. In North
  Carolina the CAP-I/DD waiver is an example of
  this.

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What is a 1915 (b)(c) Medicaid Waiver? (cont.)

• States may choose to use both sections to provide
  a continuum of services to a defined population.
  In North Carolina, this population is people with
  mental illness, intellectual/developmental
  disabilities, or substance abuse disorders.
• Within this combination, states may provide
  long-term care services using managed care tools
  while limiting the pool of providers according to
  a set of criteria which include qualifications
  and access.
• 34 states use waivers for managed care behavioral
  healthcare plans.
• States must abide by federal rules established
  for operation of these waivers.

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Components of a 1915 (b)(c) Waiver Managed Care
Organization

• Capitation provides local flexibility and
  control of resource funding.
• Payor of claims ensures that funds are spent in
  accordance with authorizations.
• Rate setting authority allows the waiver entity
  to adjust rates according to local provider
  conditions.
• Closed Provider Network allows for competition
  and choice while right sizing the marketplace
  ensures health of providers.
• Utilization Management give the waiver entity
  the tools to ensure consumers receive both the
  appropriate service and amount to meet their
  needs.
• Care Coordination an important activity that
  directly intervenes to direct consumers to the
  right level of care.

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• Questions ?

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Sandhills Centers Transition to a Local
Management Entity/Managed Care Organization
(LME/MCO)

• What will remain the Same? What will be
  improved?
• Sandhills Center will implement the Medicaid
  Waiver effective July 1, 2012.
• Customer Services will continue to have
• Toll-free telephone contact 7 days a week, 24 hrs
  per day.
• Increased Customer Services staff well equipped
  to answer questions and give immediate responses.

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CONSUMER AND FAMILY ADVISORY COMMITTEE (CFAC)

•  
• The Sandhills Center Consumer and Family Advisory
  Committee recognizes the contribution of members
  and their abilities and perspective through
  advocating for improvements in quality care
  identifying barriers, service gaps and needs as
  they arise and recommending possible solutions. 
• The committee serves as a liaison between
  Sandhills Center and the community. It is
  comprised of members and their families who
  reside within Sandhills Center geographic area. 
  To obtain further information you may contact the
  Sandhills Center CFAC staff liaison about this
  committee Toll free at 1-800-256-2452 as noted
  on our Sandhills Center Website
  www.sandhillscenter.org

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Customer Service Handbook

• A Customer Service Handbook is available to all
  of our members.  It is posted on the Sandhills
  Center Website. Handbooks can be obtained by
  calling our Customer Service Section _at_
  1-800-256-2452. The Handbook contains information
  pertaining to 1915 (b) (c) Waiver Services
  including for the entire Sandhills Center
  MH/IDD/SA population.
•  The Handbook includes the following
  information
• How Requests for Services are Prioritized
• Care Coordination Functions/ Community Guide
  Functions
• Emergency/Crisis Situations and Preparations
• Description/lists of Services/Assessment Tools
  and Practice guidelines
• Screening, Diagnosis and Treatment/Funding for
  Services
• Person Centered Planning/Access to Services

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Customer Service Handbook (cont.)

• Clinical Triage Referral Process/ Peer
  Support/TBI services
• The Provider Network/Types of Providers/Location
• Privacy Information/Human Rights/Civil Rights
• Complaint/Grievances and Appeals
  Process/Complaint form
• Appeals Process regarding Medicaid and
  Non-Medicaid Service Decisions
• Advocacy/Information/Groups
• Informational Websites
• List of Homeless Shelters/CFAC/Cultural
  Competence
• TTY Relay Calls/SHC Organizational
  Structure/Advance Directives

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Care Coordination

• Care Coordination
• Under the managed care environment of the
  1915(b)(c) Medicaid Waiver, a number of
  activities that were previously associated with
  the provider service - case management, become
  the responsibility of the Local Management Entity
  (LME)/Managed Care Organization (MCO).
• The LME/MCO refers to these functions as Care
  Coordination.
• Care Coordination is not a service. It is an
  outcomes driven function used in managed care
  systems.
• This is consistent with the way care coordination
  is provided in other healthcare settings across
  the country and is similar to the model used by
  Community Care of NC (CCNC) for the management of
  high risk consumers served by Medicaid in primary
  care practices.

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Care Coordination (cont.)

• Care Coordination Continued
• Care Coordination in the Medicaid Waiver is
  specifically focused on the unique needs of
  persons with mental health, substance abuse, and
  developmental disabilities and is designed to
  serve high need individuals and assure that
  vulnerable populations have access to needed
  care.
• Care Coordinators are community based and provide
  hands on assistance to individuals.
• The LME/MCO must meet extensive accountability
  standards, data reporting requirements, and must
  exercise risk management responsibilities.
  Under Managed Care, LME/MCOs are fully
  accountable for the quality and compliance of the
  Provider Network.

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Care Coordination (cont.)

• Care Coordination Continued
• Care Coordination in an LME/MCO provides the
  following supports to consumers
• Education about all available MH/SA/DD services
  and supports, as well as education about all
  types of Medicaid and state-funded services.
• Linkage to needed psychological, behavioral,
  educational, and physical evaluations.
• Development of the Individual Support Plan (ISP)
  or Person Centered Plan (PCP) in conjunction with
  the recipient, family, and other all service and
  support providers.
• Monitoring of the ISP, PCP, and health and safety
  of the consumer.
• Coordination of Medicaid eligibility and benefits.

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Role of MH/SA Care Coordinator

• Identify people that are in need of MH/SA Care
  Coordination.
• Ensure that people with the greatest need get
  connected with a CABHA.
• Linkage to needed MH/DD/SA resources (including
  ensuring provider choice).
• Review the Person Centered Plan and determine
  along with the provider if and when the plan
  should be changed.
• Make suggestions for enhancing a persons care
  based on clinical guidelines adopted by the
  LME/MCO.

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Role of MH/SA Care Coordinator (cont.)

• Ensure that a person with high behavioral health
  problems have both their behavioral health and
  physical health problems addressed.
• Assist in discharge planning when a person
  receives treatment via inpatient care.
• Ensure that services in the service plan are
  being provided.
• Ensure that the health and safety of a high risk
  individual is considered in the plan.
• Open communication with Community Care of North
  Carolina Management teams.

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• Questions ?

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I/DD Care Coordination for Individuals Not
Enrolled in the Innovations Waiver

• I/DD consumers not enrolled in the Innovations
  program will receive care coordination.
• Care Coordinator will
• Complete or arrange assessments to identify
  support needs
• Develop ISP
• Monitor services

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Supports Intensity Scale

• Takes the place of the NC-SNAP.
• Requirement for all I/DD consumers.
• Designed to measure the pattern and intensity of
  supports an individual with intellectual/developme
  nt disabilities requires to be successful in
  community settings.
• Occurs during the initial assessment, every two
  years, or as needs change.

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State Funded Services

• Are services that are paid with State
  appropriated funds.
• State funded services are not part of any
  entitlement program (such as Medicaid). State
  funded services are dependent upon the
  availability of funding Sandhills Center receives
  from the State.
• We adjust the benefit plan to reflect changes in
  funding availability.

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State Funded Services (cont.)

• Personal Assistance
• Developmental Therapy
• Respite
• Supervised Living
• ADVP
• Supported Employment
• Developmental Day
• Long Term Vocational Support
• TBI (Traumatic Brain Injury)
• Group Living

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Regular Medicaid Services

• Outpatient Therapy
• Psychiatric Services
• Medication Management

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1915 (b)(3) Medicaid Services

• B-3 Medicaid services allows for additional
  consumer support.
• B-3 services are dependent upon the availability
  of funding Sandhills Center receives from the
  State.
• Respite
• Supported Employment
• Long Term Vocational Support
• B-3 Deinstitutionalization Services (B-3 DI
  Services)
• Community Guide

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ICF/MR Services

• Sandhills Center will approve all ICF-MR services
  for consumers from the Sandhills Center region.
• This will include Sandhills Center consumers in
  State Developmental Centers and community ICF-MR
  placements.
• Psychological evaluations and the Sandhills
  Center ICF-MR Treatment Authorization
  Request form will be completed by a Sandhills
  Center network provider.
• Sandhills Center IDD Care Coordination services
  will ensure completion of the Level of Care
  Eligibility Determination Form.

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• Questions ?

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The Same but different

• The Community Alternatives Program for
  Individuals with Intellectual and/or
  Developmental Disabilities (CAP-I/DD)
• and
• North Carolina Innovations
• Are
• Home Community Based Services (HCBS) Waivers
• Under
• Section 1915(c) of the Social Security Act

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NC Innovations

• As of July 01, 2012 the NC Innovations Waiver
  will be implemented.
• CAP-I/DD waiver will not exist in the Sandhills
  Center catchment area.

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Transition Plan from the CAP-I/DD to the NC
Innovations Waiver

• All participants currently on the CAP-I/DD waiver
  will transition to the NC Innovations Waiver.
• All Services currently used under the CAP waiver
  (or equivalent service) are available in the NC
  Innovations waiver.
• The NC Innovations Waiver is a Comprehensive
  Waiver.
• ISP Transition-for current CAP-I/DD waiver
  participants to NC Innovations, the current
  approved Person Centered Plan will be accepted in
  the NC Innovations waiver until the next annual
  Individual Support Plan (ISP) development at the
  participants birth month.

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Transition Plan from the CAP-I/DD to the NC
Innovations Waiver

• Comprehensive and Supports Waiver participants
  will use their current CAP-I/DD budgets to ensure
  a seamless transition into the NC Innovations
  waiver until the SIS assessments and Support
  Needs Matrix category budgets can be developed by
  DMA.
• Level of Care Transition-for current CAP-MR/DD
  waiver participants to NC Innovations, the
  eligibility determination will be accepted in the
  NC Innovations waiver until the next annual
  Re-evaluation of eligibility at the birth month.

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Transition Plan from the CAP-I/DD to the NC
Innovations Waiver

• Individuals/families will be contacted by a Care
  Coordinator to discuss services prior to
  transition.
• Including meeting with the individuals PCP
  treatment team.
• As of July 01, 2012, your current TCM provider
  will not be responsible for treatment plan
  development and monitoring of services.

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CAP-I/DD to NC InnovationsServices with the same
Name

• Day Supports
• Home Modifications
• Personal Care Services
• Residential Supports
• Respite Care
• Specialized Consultation Services
• Supported Employment
• Vehicle Adaptations

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CAP-I/DD to NC InnovationsCurrent Services with
Different Names
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CAP-I/DD to NC InnovationsCurrent Services with
Different Names
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CAP-I/DD to NC InnovationsServices Not Available
Under Innovations

• Adult Day Health Care Services
• Transportation
• Enhanced Respite Care crosswalk to standard
  Respite Care as only option
• Home Supports - similar service is In Home Skill
  Building, In-Home Intensive Support and Personal
  Care
• Participant needs to contact the Care
  Coordination Department at Sandhills Center with
  any issues.

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NC InnovationsNew Service

• Community Guide
• New service to individuals transitioning from
  CAP-I/DD (optional service)

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Role of Community Guide

• Advocacy Support-includes education
• Development of community resources
• Assistance with linkage to needed supports
• Assistance with Individual and Family Directed
  Service options
• Note Care Coordinators will not perform
  functions of Community Guide

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Service Options through Innovations

• Traditional Provider Directed Option
• Individual/Family Direction Option (Self
  Direction)-Agency with Choice (Managing Employer)
• If the person tries an option and is not
  satisfied they can change.
• The person has the flexibility to direct only the
  services that they choose.

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Services that can be Individual/Family Directed

• In-Home Skill Building
• Personal Care
• In-Home Intensive Support
• Natural Supports Education
• Community Networking
• Respite
• Supported Employment
• Community Guide
• Individual Goods and Services

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NC InnovationsTargeted Case Management

• Targeted Case Management does not exist as a
  service in 1915 (b)(c) Managed Care Waivers
• Care Coordination replaces many of the functions
  of Targeted Case Management

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Role of Care Coordinator

• Educating participant/family/providers about
  services/supports, waiver requirements,
  eligibility, appeals/grievances, processes,
  options
• Assessment of support needs (completing,
  arranging for, obtaining)
• Complete Risk Assessment, Level of Care
  Assessments, Community Guide Need Survey

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Role of Care Coordinator (cont.)

• Linkage to needed MH/DD/SA resources (includes
  ensuring provider choice)
• Facilitation of Planning/Plan Development
• Monitoring plan implementation, including health
  and safety
• Medicaid eligibility coordination
• Open communication with Community Guide as
  applicable

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Limits on Services

• Cost Limit Upon admission and with continuing
  eligibility135,000 annually.
• Use of one waiver service must use one waiver
  service per month.
• Innovations waiver will have service limits as on
  the CAP-I/DD waiver. Care Coordinators will
  discuss service limits at transition meetings.

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Relatives Providing ServicesRelatives Defined

• For Adult Participants age 18 and older
• Parents
• Step-parents
• Adoptive parents
• Legal Guardians
• Other adults that live in the natural home as the
  participant

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Relatives Providing ServicesService Options

• For Adult Participants age 18 and older
• Community Networking
• Day Supports
• Personal Care
• In-Home Skill Building
• In-Home Intensive Supports
• Residential Supports
• -Only in out of home placements

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Relatives Providing ServicesConditions of
Employment

• For Adult Participants age 18 and older
• Limitations in Individual/Family Directed
  Supports options
• Consents to monthly on-site monitoring of
  services
• Service Limitations
• -Typically no more than 40 hours
• of service per week provided between
• all relatives who reside in the home
• or
• -7 daily units per week
• Prior authorization for provision of services by
  a relative or Legal Guardian is required
• Spouse of participant may not provide services

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Relatives Providing ServicesChild

• Participants under 18 years of age
• -No adult living in the natural
• home may provide periodic
• services
• -Parents, step-parents, and/or
• adoptive parents may not
• provide services
• -Legal Guardians may provide services
• in licensed residential placements

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• Questions ?

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Reference Materials

• 1915(b) State of NC MHDDSAS Plan renewal April 1,
  2011 March 31, 2013
• 1915(c) NC Innovations Waiver Draft dated
  04/01/2011
• Current DMA Clinical Coverage Policy 8M
• Proposed DMA Clinical Coverage Policy 8M
• Manual for the 2008 CAP-MR/DD Comprehensive
  Waiver
• PBH Introduction to 1915 (b)(c) Waiver Operations
  Presentation May 2011
• House Bill 916-Statewide Expansion of 1915(b)(c)
  Waiver
• Western Highlands Network on NC Innovations
  Transition November 2011

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Presenter Information

• Dorinda Robinson, MSW, LCSW, Care Coordination
  Director
• Al Gainey, LPC, I/DD Program Director
• Tena Campbell, MSW, Innovations and I/DD Clinical
  Director
• Gene McRae, Customer Service Director
• Mike Markoff, Customer Service Coordinator

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Additional Questions?

• Call Customer Services
• 1-800-256-2452
• Provider Help Desk
• 1-855-777-4652

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Community Education Advisory Group

• Ron Huber CFAC Chair
• Anthony Pugh CFAC Co-Chair
• Carol DeBerry CFAC Member
• Lori Richardson CFAC Member
• Andi Chaney SSP
• Cynthia Curtis Bethany House
• Harold Pearson Samaritan Colony
• Marcy Petti The ARC of NC
• Mary Sullivan SSP
• Nancy McNiff Sandhills Center Board of Directors
  Monarch Family Advisory Committee
• Wendy Russell The ARC of Moore
• Rita Pena Parent
• Julia English ResCare
• Tiffany Arnold ResCare
• Debbie Watson The ARC of NC
• Susie Roeder Monarch Family Advisory Committee
• Gene McRae Sandhills Center
• Mike Markoff Sandhills Center
• Al Gainey Sandhills Center

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Sandhills Center Community Education Advisory
GroupI-DD Subcommittee

• Lori Richardson CFAC Member
• Andi Chaney SSP
• Marcy Petti The ARC of NC
• Wendy Russell The ARC of Moore
• Al Gainey Sandhills Center
• Tena Campbell Sandhills Center

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Sandhills Center Consumer and Family Advisory
Committee Flyer Distribution and Forum Site
Volunteers

• Ron Huber
• Ron Unger
• Elaine Hayes
• Carol DeBerry
• Lori Richardson
• Michael Ayers
• Anthony Pugh
• Irma Robledo
• Marianne Kernan
• Chris Laughlin
• Loida Colonna
• Stephen Cohen
• Debra Collins
• Ashley Wilcox