The Future of North Carolina s Mental Health System:  1915 b c Medicaid Waivers

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What is the 1915 (b) (c) Medicaid Waiver?. A combination waiver that incorporates sections 1915 (b) and (c) of the Social Security Act (SSA)Requests that certain provisions of SSA be ?waived"Uses a capitated, managed care system as the vehicle for service provision to Medicaid recipients. Exampl

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The Future of North Carolina s Mental Health System: 1915 b c Medicaid Waivers

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1. The Future of North Carolina’s Mental Health System: 1915 (b) (c) Medicaid Waivers Guilford Center Provider Forum May 20, 2011

2. What is the 1915 (b) (c) Medicaid Waiver? A combination waiver that incorporates sections 1915 (b) and (c) of the Social Security Act (SSA) Requests that certain provisions of SSA be “waived” Uses a capitated, managed care system as the vehicle for service provision to Medicaid recipients

3. Examples of “Waived” Provisions Waives statewide uniformity Allows local control of provider rates and financial incentives Managed through a per-member/per-month capitation Allows savings to be re-invested locally Waives “any willing and qualified provider” rule Allows organization to operate a “closed” network

4. North Carolina’s Waiver Journey 2003 Piedmont Behavioral Healthcare (PBH) received approval from the NC Secretary of Health and Human Services to develop and operate a Medicaid Waiver PBH began operating under the waiver on April 1, 2005 Includes management of Medicaid, State and Federal funding for PBH consumers

5. North Carolina’s Waiver Journey (cont.)

6. North Carolina’s Waiver Journey (cont.) 2010 North Carolina Department of Health and Human Services announced its intention to implement a statewide waiver system by 2014 Two new waiver sites were announced Mecklenburg and Western Highlands Network Two hopeful waiver sites were placed in a Plan of Correction East Carolina Behavioral Health Sandhills Center

7. North Carolina’s Waiver Journey (cont.) The Guilford Center’s response: Received 3 year URAC National Accreditation Began the divestiture process for remaining services Crisis/Emergency Services by Fall 2011 Medication Management by December 2012

8. 2011 Request for Applications (RFA) Released April 1, 2011 Announced as final RFA to be issued for statewide expansion Requires full expansion by January 1, 2013 Requires lead LMEs to meet minimum qualifications by application submission May 20, 2011 If LMEs do not identify working partners, DHHS will assign LME functions to a selected waiver entity

9. Highlights of RFA Minimum Requirements for Lead LME Unduplicated Medicaid eligible population of 70,000 individuals ages 3 and older Total population of 300,000 by July 2012 and 500,000 by July 2013 Fully divested of all services at the date of application submission No legal guardianships

10. RFA Organizational Options Single LME - Performs all managed care organization (MCO) functions independently or subcontracts specific functions to one or more public, private or non-profit vendor(s) within the limits outlined in the subsequent paragraphs and throughout the RFA. Merger of two of more LMEs - Per G.S. 122C-115.3(a), a full merger can only become effective at the start of a new state fiscal year. Intra-governmental agreement among two or more LMEs - Must choose a single lead LME for both the DMA and DMH/DD/SAS contracts; LME agreement must specify how all managed care and LME functions are met for all counties included in the agreement.

11. Intra-Governmental Agreement Lead LME functions: Fiscal Agent – receives all Medicaid and State capitated funding payments Contracts with DMA and DMH to manage the waiver entity Responsible for all aspects of waiver operation and responsible for ensuring all contract requirements are met Non Lead LME functions: Based on negotiated agreement with Lead LME within confines of RFA Examples could include claims processing, customer service, information systems, provider enrollment, provider monitoring, provider credentialing, professional consultation, peer review

12. Selected Option Intra-Governmental Agreement between a group of single county LMEs with a qualifying LME applying as the Lead LME Durham responding as the Lead LME in partnership with Guilford, Cumberland and Johnston Counties Intra-Governmental Agreement to be negotiated outlining all parties responsibilities

13. Why Durham? Durham currently manages all Community Alternatives Program (CAP) service requests Currently a Medicaid Utilization Management Fee for Service pilot Fully accredited in Utilization Management by URAC Single county entity Has expressed a strong interest in maintaining as much local control and presence as possible Willing partner Medicaid population of 35,000 General population of 258,000

15. Evolving Situation Pending State legislation includes “Special Provisions” for single county LMEs House Bill 916 Proposes a July 1, 2013 implementation date Indicates county governments are not responsible for cost overruns or overspending Single county delegation meeting with the NC Secretary of Health and Human Services Details of intra-governmental agreement to be developed indicating Guilford Center functions Selection of waiver sites by August 1, 2011 Alternative arrangements after submission of RFA application to be addressed by DHHS on a case-by-case basis

16. Questions?

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