Transcript NC Innovations Waiver 1915 (c) Waiver

Sandhills Center
1915 (b)(c) Medicaid Waiver
Implementation
Presented by
Sandhills Center
Merge With Guilford County
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Laws that were passed 20 months ago increased the
minimum population size for an LME to continue to exist.
Sandhills met the amount with a population of 550,000.
However in order to better serve MH, I/DD, and SA
consumers, Sandhills Center and Guilford Center decided
to merge their operations. The merger effective date was
January 1, 2013.
The Merger Agreement was unanimously approved by the
Sandhills Center and Guilford Center Boards of Directors
along with all nine County Commissioners.
The merged agency is called Sandhills Center LME-MCO
and serves nine (9) counties. The MCO stands for
Managed Care Organization.
The Sandhills Center County of Guilford will implement the
Medicaid Waiver effective April 1, 2013
What is a
1915 (b)(c) Medicaid Waiver?
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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.
What is a
1915 (b)(c) Medicaid Waiver? (cont.)
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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.
Components of a 1915 (b)(c) Waiver
Managed Care Organization
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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.
Questions ?
I/DD Care Coordination for Individuals
Not Enrolled in the Innovations Waiver
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I/DD consumers not enrolled in the
Innovations program will receive
care coordination.
Care Coordinator will:
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Complete or arrange assessments to
identify support needs
Develop ISP
Monitor services
Supports Intensity Scale
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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/development disabilities
requires to be successful in community
settings.
Occurs during the initial assessment,
every two years, or as needs change.
State Funded Services
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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.
State Funded Services (cont.)
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Personal Assistance
Developmental Therapy
Respite
Supervised Living
ADVP
Supported Employment
Developmental Day
Long Term Vocational Support
TBI (Traumatic Brain Injury)
Group Living
Regular Medicaid Services
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Outpatient Therapy
Psychiatric Services
Medication Management
1915 (b)(3) Medicaid Services
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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
ICF/MR Services
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Sandhills Center will approve all ICF-MR services for
consumers from the Sandhills Center region.
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This will include Sandhills Center consumers in State
Developmental Centers and community ICF-MR
placements.
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Psychological evaluations and the Sandhills Center
ICF-MR Treatment Authorization Request form will be
completed by a Sandhills Center network provider.
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Sandhills Center IDD Care Coordination services will
ensure completion of the Level of Care Eligibility
Determination Form.
Questions ?
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
NC Innovations
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As of April 01, 2013 the NC
Innovations Waiver will be
implemented in Guilford County.
CAP-I/DD waiver will not exist in
the Sandhills Center catchment
area.
Transition Plan from the CAP-I/DD to
the NC Innovations Waiver
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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 participant’s
birth month.
Transition Plan from the CAP-I/DD to
the NC Innovations Waiver
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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.
Transition Plan from the CAP-I/DD to
the NC Innovations Waiver
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Individuals/families will be contacted by a
Care Coordinator to discuss services prior
to transition.
Including meeting with the individual’s PCP
treatment team.
As of April 01, 2013, your current TCM
provider will not be responsible for
treatment plan development and
monitoring of services.
CAP-I/DD to NC Innovations
Services with the same Name
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Day Supports
Home Modifications
Personal Care Services
Residential Supports
Respite Care
Specialized Consultation Services
Supported Employment
Vehicle Adaptations
CAP-I/DD to NC Innovations
Current Services with Different Names
CAP-I/DD
NC Innovations
Personal Emergency Response
System (PERS)
Assistive Technology Equipment
& Supplies
Specialized Equipment & Supplies
Assistive Technology Equipment
& Supplies and/or Individual
Goods and Services
Behavioral Consultation
Specialized Consultative Services
or Crisis Services- Behavioral
Consultation
Crisis Respite
Crisis Services-Out of Home
Crisis
Crisis Services-Primary Crisis
Response
CAP-I/DD to NC Innovations
Current Services with Different Names
CAP-I/DD
NC Innovations
Individual Caregiver Training and
Education
Natural Supports Education
Long Term Vocational Support
Supported Employment
Enhanced Personal Care
In-Home Intensive Support or
Personal Care
Community Component of Home
and Community Supports
Community Networking
Home Component of Home and
Community Support
In-Home Skill Building
CAP-I/DD to NC Innovations
Services Not Available Under Innovations
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Adult Day Health Care Services
Transportation
Enhanced Respite Care – crosswalk to
standard Respite Care as only option
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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.
NC Innovations
New Service
Community Guide
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New service to individuals
transitioning from CAP-I/DD
(optional service)
Role of Community Guide
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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
Service Options through
Innovations
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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.
Services that can be
Individual/Family Directed
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In-Home Skill Building
Personal Care
In-Home Intensive Support
Natural Supports Education
Community Networking
Respite
Supported Employment
Community Guide
Individual Goods and Services
NC Innovations
Targeted Case Management
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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
Role of Care Coordinator
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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
Role of Care Coordinator (cont.)
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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
Limits on Services
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Cost Limit: Upon admission and
with continuing eligibility:$135,000
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.
Relatives Providing Services
Relatives 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
Relatives Providing Services
Service Options
For Adult Participants age 18 and older:
 Community Networking
 Day Supports
 Personal Care
 In-Home Skill Building
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In-Home Intensive Supports
Residential Supports
-Only in out of home placements
Relatives Providing Services
Conditions of Employment
For Adult Participants age 18 and older:
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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
Relatives Providing Services
Child
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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
Questions ?
Reference Materials
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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
Presenter Information
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Victoria Whitt, CEO
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
Additional Questions?
Call Customer Services
1-800-256-2452
Provider Help Desk
1-855-777-4652