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

1. Sandhills Center 1915 (b)(c) Medicaid Waiver Implementation Presented by Sandhills Center

2. 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.

3. 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.

4. 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.

5. Questions ?

6. Sandhills Center’s 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.

7. 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

8. 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 @ 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

9. 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

10. 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.

11. 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.

12. 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.

13. 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 person’s care based on clinical guidelines adopted by the LME/MCO.

14. 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.

15. Questions ?

16. 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

17. 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/development disabilities requires to be successful in community settings. • Occurs during the initial assessment, every two years, or as needs change.

18. 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.

19. 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

20. Regular Medicaid Services • Outpatient Therapy • Psychiatric Services • Medication Management

21. 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

22. 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.

23. Questions ?

24. 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

25. 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.

26. 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 participant’s birth month.

27. 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.

28. 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 individual’s PCP treatment team. • As of July 01, 2012, your current TCM provider will not be responsible for treatment plan development and monitoring of services.

29. 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

30. CAP-I/DD to NC InnovationsCurrent Services with Different Names

31. CAP-I/DD to NC InnovationsCurrent Services with Different Names

32. 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.

33. NC InnovationsNew Service Community Guide • New service to individuals transitioning from CAP-I/DD (optional service)

34. 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

35. 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.

36. 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

37. 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

38. 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

39. 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

40. Limits on Services • 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.

41. 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

42. 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

43. 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

44. 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

45. Questions ?

46. 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

47. 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

48. Additional Questions? Call Customer Services 1-800-256-2452 Provider Help Desk 1-855-777-4652

49. Community Education Advisory Group • Ron Huber CFAC Chair • Anthony Pugh CFAC Co-Chair • Carol DeBerry CFAC Member • Lori Richardson CFAC Member • Andi Chaney SS&P • Cynthia Curtis Bethany House • Harold Pearson Samaritan Colony • Marcy Petti The ARC of NC • Mary Sullivan SS&P • 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 • Tena Campbell Sandhills Center • Jordan Medlin Sandhills Center • Robert Grooms Sandhills Center • Pam Morgan Sandhills Center • Victoria Whitt Sandhills Center

50. Sandhills Center Community Education Advisory GroupI-DD Subcommittee • Lori Richardson CFAC Member • Andi Chaney SS&P • Marcy Petti The ARC of NC • Wendy Russell The ARC of Moore • Al Gainey Sandhills Center • Tena Campbell Sandhills Center