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Understanding Services: Where and How to Get Help. Jennifer Mahan - Director of Advocacy & Public Policy. What are we going to talk about?. What are services and how are they funded? How is the system managed? Where do I get help for my child/self/family member? Q&A. What are they?

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Understanding services where and how to get help

Understanding Services: Where and How to Get Help

Jennifer Mahan - Director of Advocacy & Public Policy

What are we going to talk about
What are we going to talk about?

  • What are services and how are they funded?

  • How is the system managed?

  • Where do I get help for my child/self/family member?

  • Q&A

What are services

What are they?

Services are extra help or assistance for your family member with autism that can be applied for through the “mental health system.”

Families who have family members with disabilities or people who have disabilities can apply for these services.

Services can include help linking up with other resources, one on one instruction for people in their homes and communities, training for families and respite care.

Services are based on a plan developed after assessments and an eligibility determination process.

What are Services?

What are services who qualifies
What Are Services? Who Qualifies

  • Who Qualifies ?

    • Qualification for some NC services is based on need – not income!

    • Some services are limited to low income people

    • A diagnosis of a disability does not guarantee that someone will qualify and receive services.

    • Criteria for qualifying for NC need based services

      • Must have substantial, functional limitations in 3 or more areas of life activity

      • Life Activities: Self-care, understanding and use of language, learning, mobility, self direction, capacity for independent living

What are services funding

Who funds services?

Private Pay/Private Insurance/Other sources

Schools (for services during school day for ed.)

State Funds/IPRS and “B3”


Services vary across the state depending on who funds them and how much funding exists.

Services also vary depending on the availability of qualified providers.

What are Services? Funding

What are services funding1

Private Pay: Self (you) pay

Insurance: Coverage varies, may have coverage for physical health, mental health care, OT, speech therapy but all autism services not covered

Other: Early intervention may be covered though public health, military via Tricare and ECHO

Schools: Under Federal law (IDEA), may cover those things that assist with the child’s learning and education

What are Services? Funding

What are services medicaid

Medicaid (federal funds with state match)

“Traditional” Medicaid

Doctor visits/Emergency Room/Medication

ICF-MR (Intermediate Care Facilities)

Other LTC: Personal Care, Adult Care Home, Nursing Home

Medicaid “Enhanced” Services

Mental Health and Addiction services and supports

“B3”- basic supportive MH, IDD, SA services

EPSDT – Early Periodic Screening Diagnosis and Treatment

Catch-all funding for children – but not habilitation services

Medicaid Home and Community Based Waivers under Managed Care

NC “Innovations” Waiver under managed care

Other CAP programs for children, disabled, elderly

What are Services? Medicaid

How is the services system managed

Federal and State government provides overall funding and policy direction ($, laws, regulations)

State (MHDDSAS and Medicaid) directs funds, policies, oversight, accountability

LME MCO: Local Management Entity manages provider network, authorizes services, provides care coordination

Private providers provide services and supports

Services are paid for on a fee-for-service basis, but funds are managed using “capitation” : provider bills, LME pays out of a set amount of funding

How is the services system managed?

What do we mean by medicaid managed care

HMO type model: pre-paid, shared risk healthcare policy direction ($, laws, regulations)

Local, state and federal funds pooled into a per member per month (PMPM) rate paid to LME/MCO (“capitation”)

LME/MCO manages funds & is responsible for cost overruns, sets guidelines w/ state regarding use of $

Payment and rate structure may vary

Limits choice of provider: LME determines

Replaces case management with Care Coordination and Community Guide

LME/MCO responsible for utilization review, plan development, resource allocation, fiscal management, care coordination.

What do we mean by “Medicaid Managed Care?”

Innovations waiver basics

I/DD home and community services waiver for people is called “Innovations Waiver” and is similar to Community Alternatives Program (CAP)

Provides aggressive, goal driven, active treatment for individuals with I/DD who are not able to function safely and independently and who are at risk for placement in intermediate care facilities (ICF-MR)

Served in community/home settings

Looks only at individual income

Uses an assessment and resource allocation to determine an individual budget for services

Innovations Waiver Basics

Innovations and the wait list
Innovations and the “Wait List” “Innovations Waiver” and is similar to Community Alternatives Program (CAP)

  • Innovations is not an entitlement: limited slots and funds

  • The Wait List includes those waiting for a slot in Innovations/CAP IDD

  • The Registry of Unmet Needs includes those waiting for other services

  • Waiver slots are generally managed on a first come first serve basis

Innovations continued
Innovations Continued “Innovations Waiver” and is similar to Community Alternatives Program (CAP)

  • Some Innovations slots may be aside for specific populations (but not all LME MCOs can or do set aside slots):

    • Individuals at significant risk of harm

    • Individuals moving from another waiver

    • Individuals receiving waiver services in another state who are transferred to NC for military service

    • children 0-17 moving from an institution

Care coordination
Care Coordination “Innovations Waiver” and is similar to Community Alternatives Program (CAP)

  • Care Coordination is NOT case management

  • Care coordinators are employed by the LME MCO

  • Care coordinators can assist with individual support plans, but they set very broad goals (Providers will set specifics and shorter term goals)

  • Not everyone will have care coordination, but those on Innovations should have it

  • Meetings may occur more often over the phone, rather than in person

List of current innovations services

Innovations Services “Innovations Waiver” and is similar to Community Alternatives Program (CAP)

Assistive Technology, Equipment and Supplies (GPS and Personal Emergency Response included)

Community Guide, Community Networking, Community Transition

Crisis Services (includes some Crisis Respite, Behavioral Consultation, etc.)

Day Supports

Financial Support Service, for those with employer of record

Home and Vehicle Modifications ($ limit over 3 years)

In-Home Intensive Support

In-Home Skill Building

Personal Care

Residential Supports

Supported Employment

Respite, Nursing Respite for exceptional medical needs

Natural Supports Education

Individual Goods and Services (setup for transition from institution)

Specialized Consultation Services

(Transportation is eliminated but included in provider rate for services)

List of Current Innovations Services

What are b3 funding and state formerly iprs funds

Medicaid “B3” (MCO funds) and State Funds (IPRS) that fund additional services

They vary from MCO to MCO

[MCO staff has info on what services are available in your area]

What are “B3” Funding and State (Formerly IPRS) Funds?

Alliance b3 services
Alliance B3 Services fund additional services

  • Alliance currently has Community Guide and Respite B3 services

  • Alliance may have some Personal Assistance, Developmental Therapy, and Employment IPRS funded services – the availability of these servceis varies by which county you live in

Understanding services where and how to get help

Additional (b)(3) Medicaid Services fund additional services

(for Cardinal Healthcare Region Only)

November 2012

Not in alliance or cardinal
Not in Alliance or Cardinal? fund additional services

  • Check the map earlier in the presentation to find your LME MCO or view the map here: http://www.ncdhhs.gov/mhddsas/lme-mcomap10-13.pdf

  • Check the list of local contact to find your county and LME MCO http://www.ncdhhs.gov/mhddsas/lmeonblue.htm

Asnc services triangle

ASNC offers services in the Triangle region: fund additional serviceshttp://www.autismsociety-nc.org/index.php/get-help/direct-care/raleigh-autism-society-of-north-carolina-office

Talk about how to access services and supports

Alliance Website for Individuals and Families: http://www.alliancebhc.org/consumers-families

ASNC Services - Triangle

Asnc services cardinal and statewide

ASNC offers services in fund additional servicesother regions of the state, including some of those served by Cardinal: http://autismsociety-nc.org/index.php/get-help/direct-care/autism-society-of-nc-services-offices

Talk about how to access services and supports

Cardinal Innovations Healthcare Solutions : http://www.cardinalinnovations.org/consumerfamily/

ASNC Services – Cardinal and Statewide

Being your own case manager
Being Your Own Case Manager fund additional services

  • Stay in contact with LME & care coordinator

  • Come prepared with the goals you want to work on

  • Work with provider agency on goals

  • Ask what resources are available: ask for what you need

  • Get and retain documentation of needs

  • Document all conversations with the LME and providers (date, time, what was concern, what solutions were offered, what was outcome)

Complaints fund additional services

  • Each MCO has a grievance process that notes complaints that are not related to reductions in services

  • Complaints can be about anything:

    • Quality of care from provider

    • Problems with care coordination

    • Problems getting the right information

    • Impact of cuts on service provider

    • Problems getting “enrolled” in services (access)

    • Other situations that come up

Appealing reduction in innovations waiver medicaid services
Appealing Reduction in Innovations Waiver Medicaid Services fund additional services

  • MCO must provide written notification of decision to reduce, deny, terminate services

  • Under MCO, you have a set number of days to begin appeals process

    • 1st step is internal review (peer review)

    • Mediation may take place

    • Next level is informal OAH hearing

  • See Information on MCO website

Weblinks: fund additional services

  • Alliance LME MCO

    • IPRS services http://www.alliancebhc.org/iprs-adult-and-child-idd-benefit-plan

    • IDD resources http://www.alliancebhc.org/consumers-families/idd-resources

  • Cardinal Innovations Healthcare

    • Accessing Services http://www.cardinalinnovations.org/consumerfamily/services.asp

    • Innovations Waiver http://www.cardinalinnovations.org/innovations/

Weblinks: fund additional services

  • NC Department of Health and Human Services

    • Division of MH/DD/SAS: http://www.ncdhhs.gov/mhddsas/

    • 1915 b/c Waiver:


    • Medicaid:


Contact info
Contact Info fund additional services

  • Jennifer Mahan, Dir. of Advocacy & Public Policy

    ASNC Raleigh Office


    Tel: 919-865-5068

  • Kerri Erb, Senior Director of Programs and Quality

    ASNC Raleigh Office


    Tel: 919-865-5053