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

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Sandhills Center 1915 (b)(c) Medicaid Waiver Implementation. Presented by Sandhills Center. Merge With Guilford County.

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merge with guilford county
Merge With Guilford County
  • Laws that were passed 20 months ago increased the minimum population size for an LME to continue to exist. Sandhills met the amount with a population of 550,000. However in order to better serve MH, I/DD, and SA consumers, Sandhills Center and Guilford Center decided to merge their operations. The merger effective date was January 1, 2013.
  • The Merger Agreement was unanimously approved by the Sandhills Center and Guilford Center Boards of Directors along with all nine County Commissioners.
  • The merged agency is called Sandhills Center LME-MCO and serves nine (9) counties. The MCO stands for Managed Care Organization.
  • The Sandhills Center County of Guilford will implement the Medicaid Waiver effective April 1, 2013
what is a 1915 b c medicaid waiver
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.
what is a 1915 b c medicaid waiver cont
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.
components of a 1915 b c waiver managed care organization
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.
i dd care coordination for individuals not enrolled in the innovations waiver
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
supports intensity scale
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.
state funded services
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.
state funded services cont
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
regular medicaid services
Regular Medicaid Services
  • Outpatient Therapy
  • Psychiatric Services
  • Medication Management
1915 b 3 medicaid services
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
icf mr services
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.
the same but different
The Same but different…

The Community Alternatives Program for Individuals with Intellectual and/or Developmental Disabilities (CAP-I/DD)


North Carolina Innovations


Home & Community Based Services (HCBS) Waivers


Section 1915(c) of the Social Security Act

nc innovations
NC Innovations
  • As of April 01, 2013 the NC Innovations Waiver will be implemented in Guilford County.
  • CAP-I/DD waiver will not exist in the Sandhills Center catchment area.
transition plan from the cap i dd to the nc innovations waiver
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.
transition plan from the cap i dd to the nc innovations waiver1
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.
transition plan from the cap i dd to the nc innovations waiver2
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 April 01, 2013, your current TCM provider will not be responsible for treatment plan development and monitoring of services.
cap i dd to nc innovations services with the same name
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
cap i dd to nc innovations services not available under innovations
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.

nc innovations new service
NC InnovationsNew Service

Community Guide

  • New service to individuals transitioning from CAP-I/DD (optional service)
role of community guide
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

service options through innovations
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.
services that can be individual family directed
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
nc innovations targeted case management
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
role of care coordinator
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
role of care coordinator cont
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
limits on services
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.
relatives providing services relatives defined
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
relatives providing services service options
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

relatives providing services conditions of employment
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


-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
relatives providing services child
Relatives Providing ServicesChild
  • Participants under 18 years of age

-No adult living in the natural

home may provide periodic


-Parents, step-parents, and/or

adoptive parents may not

provide services

-Legal Guardians may provide services

in licensed residential placements

reference materials
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
presenter information
Presenter Information
  • Victoria Whitt, CEO
  • 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
additional questions
Additional Questions?

Call Customer Services


Provider Help Desk