Division of Medical Assistance (DMA) Updates

1. Division of Medical Assistance (DMA) Updates 2012 Annual Housing Conference September 27, 2012 Tara Larson Chief Clinical Operating Officer/Deputy Director

2. What is Medicaid Today • Title XIX of the Social Security Act (Medicaid) is a federal entitlement program that pays for medical assistance for certain individuals with low income and resources. • Funding is made up of dollars from the federal government and state resources. • It is very complex and has many, many rules and guidelines • The federal agency that administers Medicaid is CMS – The Center for Medicaid and Medicare Services • Medicaid and Medicare are not the same.

3. The federal government establishes very broad rules and then allows each state to: • Establish its own eligibility standards • Determine type, amount, duration and scope of service (what, how much and what conditions) • Set the rate and payment for the services • Administer the program • As a result, a person who is eligible in one state may not be eligible in another or services offered in one state are not the same in another state. • As part of the broad rules, the federal government must approve what a state pays for, how a person is determined to be eligible, how rates are set and other aspects of the administration of the program. • SPAs • Waivers • Option Applications • Demonstration Projects

4. WHAT IS COVERED TODAY by Medicaid? Ambulance Children’s Dental Durable Medical Equipment Family Planning Early Periodic Diagnosis Screening and Treatment (EPDST) Children’s Hearing Aids Clinics Home Health Hospital Services Midwife and Nurse Practitioner Nursing Facility Other Lab and X-ray Physician Psychiatric Residential Treatment Facilities (PRTFS) Routine Eye Examinations and Visual Aids for Children Case Management Chiropractor Podiatry CAP Programs Adult Dental and Dentures HMO Membership Home Infusion Therapy Hospice ICF-MR Mental Health Personal Care Orthotics and Prosthetics Prescription Drugs PT, OT and Speech Therapy Private Duty Nursing Respiratory Therapy Transportation Mandatory Services Optional Services 4

5. Overview of Health Reform • By January 1, 2014, the bill requires most people to have health insurance and most employers to provide affordable health insurance or pay a penalty. • Most low-income people will be eligible for Medicaid. • Most low- and moderate-income individuals and families will be eligible for subsidies to help pay for private insurance, unless they have employer or governmental insurance. • Employers with 50 or more employees will be required to offer affordable insurance coverage or pay a penalty. • Small employers will be exempt from mandates, but some will be eligible for tax credits if they offer insurance to their workers.

6. Overview of Health Reform • The legislation expands health insurance coverage by: • Covering more people and making it more affordable to many. • Covering preventive services and essential health benefits. • The legislation provides new funding for: • Health promotion and wellness initiatives. • Expansion of the safety net. • Health professions education and workforce. • The legislation includes an emphasis on improving quality and efforts to reduce unnecessary health care costs.

7. Medicaid (cont’d) • Will I qualify for Medicaid under health reform? • If you qualify for Medicaid now, you should be able to qualify in 2014 (assuming your income stays about the same). • Beginning in 2014, the bill expands Medicaid to cover all low-income people under age 65 with incomes up to 133% of the federal poverty level (FPL), based on modified gross income. • NC will need to decide if they will expand Medicaid to 133% - no longer a federal mandate (Supreme Court Decision) • Undocumented immigrants will not be eligible for regular Medicaid coverage, regardless of how poor.

8. What Plans Will be Available in the HIE? • What kinds of health insurance plans will be available to purchase in the Health Insurance Exchanges? • All of the plans offered through the Health Insurance Exchanges (HIEs) will include the essential health benefits. • Insurers will offer bronze, silver, gold, and platinum plans through the HIE with varying levels of coverage. For example “silver” plans will pay, on average, 70% of the covered health care costs. You will be responsible for paying the remaining 30% of covered health care costs out of pocket. • In general, the higher the level of plan, the more a person will pay in premiums but the less they will pay in out-of-pocket costs.

9. Where is Housing Covered? • It is not…. • Housing is only billable in Medicaid for “institutional level of care” • Nursing Homes • ICF-MR/DD • That is what has caused some of the concerns nationally and made CMS make changes in their policies of where other services can occur • MFP • DOJ • The push is settings less than 4 beds and also independent housing arrangements • Scattered sites • Individual leases • Housing and services not tied together.

10. CCNC—NC Health/Medical Home • CCNC is the Health Home for NC Medicaid recipients.  • 1.6 million people on Medicaid • 1.2 million assigned to a Health/Medical Home • CCNC is responsible for the following for patients with “chronic conditions*”: • Comprehensive care management • Care coordination/health promotion • Comprehensive transitional care • Patient and family support • Referrals to community and social support services • Use of HIT to link services • *including serious/persistent mental illness and substance abuse disorders

11. Behavioral Health (MH/DD/SA Services) • Moving from a fee for service model to a managed care, at risk, capitated system • Is a phased roll out approach • Statewide by July 1, 2012 • Responsible for managing not only day to day behavioral health services but also the implementation of the DOJ settlement

12. Proposed Local Management Entity - Managed Care Organizations (LME-MCOs) and their Member Counties on January 1, 2013 Central Region Eastern Region Western Region East Carolina Behavioral Health CenterPoint Human Services Apr 2012 Jan 2013 Smoky Mountain Center Alleghany Northampton Camden Currituck Jul 2012 Ashe Person Gates Rockingham Warren Surry Stokes Caswell Vance Pasquotank Hertford Halifax Perquimans Wilkes Granville Watauga Yadkin Orange Chowan Forsyth Guilford Franklin Bertie Avery Alamance Mitchell Durham Caldwell Nash Davie Yancey Alexand er Edgecombe Madison Washington Iredell Davidson Wake Martin Burke Tyrrell Dare Chatham Randolph Catawba Wilson McDowell Rowan Buncombe Beaufort Pitt Haywood Johnston Lincoln Greene Hyde Lee Swain Rutherford Cabarrus Henderson Montgomery Graham Harnett Gaston Jackson Wayne Polk Stanly Moore Lenoir Craven Cleveland Transylvania Mecklenburg Cherokee Macon Cumberland Pamlico Clay Richmond Sampson Jones Union Anson Hoke Duplin Western Highlands Network Mecklenburg Onslow Scotland Carteret Jan 2012 Jan 2013 Robeson Sandhills Bladen Durham/ Wake/ Pender Partners Behavioral Health Management Center/ Johnston/ Cumberland (Pathways/ MH Partners/ Crossroads) Guilford Columbus New Jan 2013 Jan 2013 Dec 2012 Hanover Brunswick Eastpointe/ Coastal Care System PBH/ Alamance Caswell Oct 2011/ Southeastern Regional/ (Southeastern Center/ OCBHS) Five County Jan 2012/ Beacon Center Jan 2013 OPC Apr 2012 Jan 2013 Unless otherwise indicated, the LME name is the county name(s). The lead LME name for the proposed LME-MCO is shown first. Dates shown are the planned Waiver start dates. Reflects plans as of February 9, 2012.

13. Medicaid Personal Care Services Will there be impact in housing?

14. Personal Care Services (PCS) Background • Session Law 2012-142, HB 950: • Personal Care Services (PCS) benefits for children and adults • Consolidates services for recipients in private residences and adult care homes, group homes, and combination facilities • Extends Independent Assessment (IA) requirement to recipients in licensed homes • Raises PCS eligibility requirements for recipients in licensed homes to same level as private residences • Eliminates essential errands as an allowable use of PCS services • No other impact for recipients under 21 years due to EPSDT requirements – a federal requirement that each state must follow that requires services be provided to correct or ameliorate conditions and meet conditions of section 1905a of the federal rules.

15. New PCS Eligibility(Under Session Law 2012-142, HB 950) • Eligible adult recipients: • Have medical condition, disability, or cognitive impairment, and • Require limited hands-on assistance with three activities of daily living (ADLs), • or hands-on assistance with two ADLs including one at the extensive assistance level • or hands-on assistance with two ADLs including one at full dependence level • Qualifying ADLs are: • bathing, dressing, mobility, toileting, and eating

16. How is PCS Paid (before Session Law 2012-142, HB 950?) IN-HOME PCS FACILITIES Daily rate Basic (1-30 beds) - $16.62 Basic (31 and above) - $18.21 Enhanced Eating - $10.26 Toileting - $3.67 Eating/Toileting - $13.92 Ambulation/Locomotion - $2.62 Special Care Units 1-30 beds basic plus - $44.44 31 and above basic plus - $48.68 Transportation - $ .57 • 15 minute unit - $3.47 • Maximum 80 hours per month except for children • Children may exceed 80 hours due to EPSDT

17. How will PCS be paid as a result of SL 2012-142, HB 950? • The PCS State Plan submitted to CMS must be comparable in all areas • Payment methodology will be the same across locations (in- home and facilities) • -- 15 minute unit ($3.88)

18. Status of Implementation of the Changes (SL 2012-142) State Plan Amendment submitted to change PCS • Makes eligibility, payment methodology and process the same across settings • July 20, 2012—DHHS applied to CMS for a Medicaid State Plan Amendment (SPA) to implement the required legislative changes • Request for Additional Information (RAI) was received on August 13, 2012. Questions are about • -- limitations of hours and process for determining • scope and duration • -- Qualifications of providers, supervision of staff, • use of nurse aide registry • -- Allowable locations of services and type of provider • -- Provider Choice

19. Status of Implementation of the Changes (SL 2012-142) (continued) • Independent Assessment (IA) Vendor: • July 1, 2012—DMA extended Independent Assessment (IA) contract with The Carolinas Center for Medical Excellence (CCME) • CCME has been conducting the IA for the in-home program • This amendment allowed for the immediate implementation of IA for recipients in facilities, leveraging existing cost and resources in place for the in-home program • A Request for Proposal (RFP) was posted August 22, 2012 for an IA vendor who will conduct both the in-home and facility PCS • Closing September 25, 2012 • Effective date of new contract: • January 1, 2013 for a planned transition period with current vendor

20. Results of Assessments 8/30/2012 Setting Assessments Completed PCS Non- Qualifying PCS Non- Qualifying Count Percent Count Percent ACH Bed in NF 298 144 49% 154 52% Adult Care Home 2,326 1,240 53% 1,086 47% Family Care Home 246 84 34% 162 66% SLF 5600a 88 16 18% 72 82% SLF 5600c 218 65 30% 153 70% Special Care 715 566 79% 149 21% GRAND TOTAL 3,891* 2,115 54% 1,776 46% * Entered into database Note. Results reflect approximately 66 percent of assessments completed to date; medical attestation forms have not yet been submitted for the additional 34 percent of completed assessments. These assessments do not represent a valid sample of residents in the facilities.

21. NO NO Residential FacilitiesPhase II IMD Process Determining if a Residential Facility is an IMD Is the current need for institutionalization of 50% or more of residents (using licensed beds) a direct result of a mental health/substance abuse illness being the reason for the placement? Is the overall character of the facility is primarily for the care and treatment of individuals with MH/SA? Define the institution – which means what facilities are being examined The institution is an IMD YES YES Are there 17 or more beds in the institution? The institution is not an IMD 21

22. DHHS Policy Response to DOJ Findings Letter Will there be impact on housing?

23. Agreement Components • In-reach • Diversion • Transition planning • Housing slots with rental assistance and transition supports • ACTT fidelity • Supported Employment • Quality Assurance and Performance Improvement • Independent Reviewer

24. Transition Planning • Establish teams coordinated by LME-MCO and headed by Transition Coordinator • Adult Care Homes and State Hospitals with priority on ACH IMDs • DHHS trains transition team based on MFP process and protocols • Establish interest list and tracking mechanism

25. Diversion from Adult Care Homes • MUST – Medicaid Uniform Screening Tool • Use of MUST by January 2013 to identify individuals with MH needs seeking admission to ACH • If identified, referred to services

26. Supported Housing Slots • Package of rental subsidy, one-time transition supports, community services • Total of 3,000; 100-300 in first year • First come first served and based on geographic housing availability and individual preference • Interest list up to twice the slots of current and subsequent year • Build upon current infrastructure for rental assistance associated with targeted/key housing program

27. ACTT Fidelity • Fidelity assessment is important for implementation of evidence-based practices (EBPs), including assertive community treatment (ACT). • Assertive Community Treatment Team (ACTT) • By July 2013 all teams must meet fidelity and will have at least 33 teams serving 3,225 individuals. • By July 2019 50 teams serving 5,000 individuals • Determine which fidelity: DACT (Dartmouth Assertive Community Treatment) or TMACT (Tools for Measurement of ACT) • Training • Identify who will do fidelity assessment • Service definition changes and rate revision

28. Supported Employment • Evidence based model – Dartmouth Fidelity Scale • 100 individuals by July 2013 building to 2,500 individuals by July 2019. • Involves both SE and Long-Term Vocational Supports • Need to determine what model • Service definition and rate setting

29. Quality Assurance and Performance Improvement • Tracking length of stay, readmissions, community tenure • Personal Outcomes including: -- Incidents of harm -- Repeat admissions -- Use of crisis beds and community hospital admissions -- Repeat ED visits -- Time spent in congregate day programming -- Number employed, attending school, maintenance of living arrangement, engaged in community life • In-reach and discharge • Quality of Life Surveys • External Quality Review (EQRO)

30. Independent reviewer • Conduct initial baseline evaluation • Evaluate status of compliance • Produce annual reports

31. QUESTIONS?