Presentation on theme: "Sandhills Center 1915 (b)(c) Medicaid Waiver Implementation"— Presentation transcript:
1Sandhills Center 1915 (b)(c) Medicaid Waiver Implementation Presented bySandhills Center
2Merge 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
3What 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 sectionThis 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.
4What 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.
5Components 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.
7Care Coordinator will: I/DD Care Coordination for Individuals Not Enrolled in the Innovations WaiverI/DD consumers not enrolled in the Innovations program will receive care coordination.Care Coordinator will:Complete or arrange assessments to identify support needsDevelop ISPMonitor services
8Supports 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.
9State Funded ServicesAre 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.
10State Funded Services (cont.) Personal AssistanceDevelopmental TherapyRespiteSupervised LivingADVPSupported EmploymentDevelopmental DayLong Term Vocational SupportTBI (Traumatic Brain Injury)Group Living
121915 (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.RespiteSupported EmploymentLong Term Vocational SupportB-3 Deinstitutionalization Services (B-3 DI Services)Community Guide
13ICF/MR ServicesSandhills 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.
15The Same but different… The Community Alternatives Program for Individuals with Intellectual and/or Developmental Disabilities (CAP-I/DD)andNorth Carolina InnovationsAreHome & Community Based Services (HCBS) WaiversUnderSection 1915(c) of the Social Security Act
16NC InnovationsAs 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.
17Transition 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.
18Transition 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.
19Transition 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.
20CAP-I/DD to NC Innovations Services with the same Name Day SupportsHome ModificationsPersonal Care ServicesResidential SupportsRespite CareSpecialized Consultation ServicesSupported EmploymentVehicle Adaptations
21CAP-I/DD to NC Innovations Current Services with Different Names Personal Emergency Response System (PERS)Assistive Technology Equipment & SuppliesSpecialized Equipment & SuppliesAssistive Technology Equipment & Supplies and/or Individual Goods and ServicesBehavioral ConsultationSpecialized Consultative Services or Crisis Services- Behavioral ConsultationCrisis RespiteCrisis Services-Out of Home CrisisCrisis Services-Primary Crisis Response
22CAP-I/DD to NC Innovations Current Services with Different Names Individual Caregiver Training and EducationNatural Supports EducationLong Term Vocational SupportSupported EmploymentEnhanced Personal CareIn-Home Intensive Support or Personal CareCommunity Component of Home and Community SupportsCommunity NetworkingHome Component of Home and Community SupportIn-Home Skill Building
23CAP-I/DD to NC Innovations Services Not Available Under Innovations Adult Day Health Care ServicesTransportationEnhanced Respite Care – crosswalk to standard Respite Care as only optionHome Supports - similar service is In Home Skill Building, In-Home Intensive Support and Personal CareParticipant needs to contact the Care Coordination Department at Sandhills Center with any issues.
24NC Innovations New Service Community GuideNew service to individuals transitioning from CAP-I/DD (optional service)
25Role of Community Guide Advocacy Support-includes educationDevelopment of community resourcesAssistance with linkage to needed supportsAssistance with Individual and Family Directed Service optionsNote: Care Coordinators will not perform functions of Community Guide
26Service Options through Innovations Traditional Provider Directed OptionIndividual/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.
27Services that can be Individual/Family Directed In-Home Skill BuildingPersonal CareIn-Home Intensive SupportNatural Supports EducationCommunity NetworkingRespiteSupported EmploymentCommunity GuideIndividual Goods and Services
28NC Innovations Targeted Case Management Targeted Case Management does not exist as a service in 1915 (b)(c) Managed Care WaiversCare Coordination replaces many of the functions of Targeted Case Management
29Role of Care Coordinator Educating participant/family/providers about services/supports, waiver requirements, eligibility, appeals/grievances, processes, optionsAssessment of support needs (completing, arranging for, obtaining)Complete Risk Assessment, Level of Care Assessments, Community Guide Need Survey
30Role of Care Coordinator (cont.) Linkage to needed MH/DD/SA resources (includes ensuring provider choice)Facilitation of Planning/Plan DevelopmentMonitoring plan implementation, including health and safetyMedicaid eligibility coordinationOpen communication with Community Guide as applicable
31Limits on ServicesCost 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.
32Relatives Providing Services Relatives Defined For Adult Participants age 18 and older:ParentsStep-parentsAdoptive parentsLegal GuardiansOther adults that live in the natural home as the participant
33Relatives Providing Services Service Options For Adult Participants age 18 and older:Community NetworkingDay SupportsPersonal CareIn-Home Skill BuildingIn-Home Intensive SupportsResidential Supports-Only in out of home placements
34Relatives Providing Services Conditions of Employment For Adult Participants age 18 and older:Limitations in Individual/Family Directed Supports optionsConsents to monthly on-site monitoring of servicesService Limitations-Typically no more than 40 hoursof service per week provided betweenall relatives who reside in the homeor-7 daily units per weekPrior authorization for provision of services by a relative or Legal Guardian is requiredSpouse of participant may not provide services
35Relatives Providing Services Child Participants under 18 years of age-No adult living in the naturalhome may provide periodicservices-Parents, step-parents, and/oradoptive parents may notprovide services-Legal Guardians may provide servicesin licensed residential placements
37Reference Materials1915(b) State of NC MHDDSAS Plan renewal April 1, 2011 – March 31, 20131915(c) NC Innovations Waiver Draft dated 04/01/2011Current DMA Clinical Coverage Policy #8MProposed DMA Clinical Coverage Policy #8MManual for the 2008 CAP-MR/DD Comprehensive WaiverPBH Introduction to 1915 (b)(c) Waiver Operations Presentation May 2011House Bill 916-Statewide Expansion of 1915(b)(c) WaiverWestern Highlands Network on NC Innovations Transition November 2011
38Presenter Information Victoria Whitt, CEODorinda Robinson MSW, LCSW, Care Coordination DirectorAl Gainey, LPC, I/DD Program DirectorTena Campbell, MSW, Innovations and I/DD Clinical DirectorGene McRae, Customer Service DirectorMike Markoff, Customer Service Coordinator
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