Medicaid Waivers Managed Care 1915 b (NC MH/DD/SAS Health Plan) Home & Community Based Services/HCBS 1915 c (NC In

1. Medicaid Waivers Managed Care 1915 b (NC MH/DD/SAS Health Plan) Home & Community Based Services/HCBS 1915 c (NC Innovations) Kelly Crosbie, LCSW Behavioral Health Manager Division of Medical Assistance (DMA)

2. Medicaid Waiver • DMA (Medicaid) gets a 1915b/c waiver from CMS (Centers for Medicare & Medicaid) • This waiver allows us to let a managed care company (LME) run the Medicaid program for mh/sa/dd services in their counties. • Allows us to offer HCBS (habilitation) • “Mini Medicaid Program” • We (DMA) monitor the company (LME) to make sure that they follow all Medicaid rules. • CMS monitors DMA

3. What does the Company (LME) do for Medicaid? • Enroll & monitor providers (statewide) • Call Center—Customer Support • Make sure consumers with greatest need get connected to providers and have treatment plans (Care Coordination) • Authorize “medically necessary” services • Pay for mh/sa/dd services • Provide education about ALL Medicaid benefits to recipients & consumers (website, mailings, seminars) • Reviews, Medications, OAH Hearings (Due Process) • Gap analysis/community development • CCNC collaboration

4. “Care Coordination for Special Health Care Needs” vs. Targeted Case Management • Care Coordination (42 CFR 438.208(c)) • I/DD (eligible for Innovations) • Innovations waiver recipient • Adult SPMI & LOCUS score • Child SED & CALOCUS score • Substance Dependence & ASAM level • Opioid Dependent & IV-use • Dual Diagnosis & LOCUS/ASAM level • Identify • Assure Treatment Plan exists • Assure access to all assessments & specialists • Episodic & Time-limited

5. What else does DMA require of the Managed Care Company (LME) • They must hire disability-specific specialists • Psychiatrists • Psychologists • I/DD Qualified Professionals • Licensed mental health professionals (LCSW, LPC) • Licensed substance abuse professionals (LCAS) • Robust Quality Management Process • Provider & consumer involvement • DMA, DMHDDSAS, 2 external vendors monitor the managed care company (LME)—monthly, quarterly, yearly (on all operations)

6. “At-Risk” Benefits • They can develop their own Utilization Management (UM) criteria, Level of Care (LOC), Length Of Stay (LOS) • They can do “care management”—have clinical discussions with providers • Use the Treatment Authorization Request (TAR) but they can ask for additional information • Limit their provider network (after initial offer of contract to all Medicaid providers) • Pay differential rates—for specialty care, for crisis services, for performance; can use case rates or sub-capitation

7. How does DMA pay the managed care company (LME) • We pay the company (LME) a monthly payment • With that the company (LME) pays providers for all services and supports (RISK RESERVE) • How do we (DMA) determine how much to pay? • History of spending for mh/sa services • Assume increased # of consumers get services • “Recovery model” • History of spending for CAP services (I/DD) • Assume life-long need, often increased need for services; Based on slots

8. “Extra Services”: b3 Services • Projected savings from better management of care & network • Inpt, ED use, LOS in residential treatment, pay for outcomes • Supports Intensity Scale (SIS)* • Extra services that benefit the population • PBH: robust array (mature network) • New LME-MCOs • Respite* (children, Innovations waitlist) • Community Guide (Innovations waitlist) • Peer Support Services (MH/SA consumers)

9. Supports Intensity Scale (SIS)/Support Needs Matrix (SNM) • Approved by CMS for use in NC • SIS used for planning purposes (AAID) • Used to develop funding levels in: OR, CO, LA, GA, WA, RI, 2 Canadian provinces; (in-process) NC, UT, MA, ME, ND • “Support Needs Matrix” (SNM) (HSRI) • PBH has spent 18 months on community engagement • Currently in 4-stage transition process • **CAP MR/DD services crosswalk to Innovations services

10. North Carolina Roll-Out • HB 316 (PBH), HB 916 (expansion to other LMEs) • PBH has been operating under these waivers for ~6 years (expanding Oct 2011-April 2012) • Western Highlands Network (WHN)—January 2012 • East Carolina Behavioral Health (ECBH) and Sandhills Center (Spring-July 2012) • RFA out: final start dates by January 2013 • All LMEs have applied individually or as part of a collaborative effort

11. CCNC & LME-MCO Collaboration • CCNC = NC HealthHome • LME-MCO is vital partner that supports HealthHome • Shared Care Management of recipients • Identification, linkage to services • Coordination of MH/SA/DD & physical health needs • Data exchange into Informatics • Collaboration on integrated care practices • Monthly-quarterly partnership meetings

12. Community Transitions • CAP-C & CAP-DA (impact = better collaboration) • Emergency transition slots, CAP-C transitions • *GOAL*--have 2 dedicated MFP slots • “Reserve slot”—take Innovations or CAP MR/DD slot with you from county-to-county • Other b3 services (at PBH) support transition • PBH has reinvested funds into community collaboratives (to develop community resources) • Waiver requires attention to barriers to treatment • NC START (not yet a Medicaid service) • State-funded only

13. Other Answers • State Developmental Centers & ICFs-MR are included in the capitation • The MCOs can negotiate rates and work on building community capacity • Rate cuts? –can occur after yearly capitation setting with DMA • PBH pays Medicaid rate or better • Validated rate-setting process

14. QUESTIONS

15. Medicaid/DMA Contacts Kelly Crosbie, LCSW 919-855-4293 Kelly.crosbie@dhhs.nc.gov Kathy Nichols, LCSW 919-855-4289 Katherine.nichols@dhhs.nc.gov http://www.ncdhhs.gov/dma/lme/MHWaiver.htm