1. 1 “ Responsible Change to Achieve Easy Access, Better Quality and Personal Outcomes” Presentation by: Kathy Nichols, DMA Mabel McGlothlen, DMH Save Our Planet, Save Our Wildlife! Partnering for Success: The 1915 (b)/(c) Medicaid Waiver & DHHS Strategic Implementation Plan Update NC School Community Health Alliance Conference December 4, 2012

2. 2 Priority of DHHS, DMA & DMHDDSAS Start Date: July 1, 2010 Expansion Completion Date: July 1, 2013 o Building success upon success o Improving quality and effectiveness o Increasing accountability for all stakeholders o Contain Medicaid Cost o Increasing consumer/family/stakeholder confidence in the MH/DD/SA provider network o Priority tasks: o 1915 b/c Waivers o Provider Quality

3. 3 The Vision 1915 B/C Medicaid Waiver The State CAP-MR/DD Waiver Overarching Goal: To successfully provide easily accessible, high quality, cost effective MH/DD/SA services and supports that result in person-centered outcomes for individuals served. Building success one step at a time. 2010 201220112013Future Provider Quality

4. 4 DHHS 1915 b/c Waiver Goals Start Date: April 2009 RFA Selection Date: July 1, 2010 1. Improve access to MH/DD/SAS Services. 2. Improve quality of MH/DD/SAS Services. 3. Improve outcomes for people receiving MH/DD/SAS Services. 4. Improve access to primary care for people with mental illness, developmental disabilities and substance abuse. 5. Improve cost benefit of services. 6. Effectively manage all public resources assigned to the MCOs.

5. 5 DMHDDSAS Reform & DMA Waiver History History: 20012010  2001 – State Plan 2001: Blueprint for Change (41 APs)  2003 – LMEs Local Business Plan submissions… PBH  2005 – Through DMA, CMS awarded PBH, the right to administer and manage a State 1915 b/c waiver as a pilot project for the delivery of publicly funded MH/DD/SA services operating in Cabarrus, Davidson, Rowan, Stanly, and Union Counties.  April 2009 – Legislative Report Medicaid Waivers for LMEs S.L. 2008-0107 Section 10.15(y)  In May 2009 – The Secretary requested that DMH and DMA develop a 1915 b/c Medicaid waiver amendment for Statewide waiver expansion, replicating PBH’s waiver, for submission to CMS by Dec. 15, 2009

6. 6 First Round of Request For Applications (RFA’s) Start Date: April 2010 RFA Selection Date: July 2010  SESSION 2009, SL-2010-31 / SB 897; Section 10.24  RFA Process, the State can select two waiver entities; PBH cannot expand; complete a Legislative Report;  Legislative Report: an evaluation: I/DD consumers survey and ICF-MR Facility Impact  RFA Applications received – April 2010  Mecklenburg, Western Highland Network, Sandhills Center and ECBH.  DHHS RFA Announcement Selection – July 2010  Mecklenburg and Western Highland Network

7. 7 Session Law 2011 – 264, House Bill 916 Start Date: July 1, 2011 Expansion Completion Date: July 1, 2013  House Bill 916  ECBH and SHC allowed to go forward Waiver Implementation plans based upon original application  PBH allowed to expand /cancelling SB 897 (SB316)  New LME population requirements 300K – 2012 / 500K – 2013 (consistent with RFA requirements)  By October 1, 2011 submit a strategic plan delineating specific strategies and agency responsibilities for the achievement of statewide expansion of the 1915 (b)/(c) Medicaid Waiver.  RFA Selection Announcement by August 2011  DHHS – January 2013 / July 2013 – Complete unassigned LME Programs.

8. 8 Second Round RFA Start Date: July 1, 2011 Expansion Completion Date: July 1, 2013  RFA Applications Submission – May 2011  PBH Expansion Notice (A-C, Five County, OPC)  CenterPoint; Durham Center (Johnston, Guilford, Cumberland); Eastpointe (Beacon, SER); Pathways (MHP, Crossroads); Smoky Mountain; Southeastern Center (Onslow-Carteret); and Wake County  July 26 th - Successful Application Reviews: Eastpointe; Pathways; and Smoky Mountain  RFA Applications resubmission / Final Selection  Durham Center – July  CenterPoint and Southeastern Center – November

9. 9 Final LME-MCO Merger Map

10. 10 LME-MCO Implementation Time Line GOALS: 1. Improve access to MH/DD/SAS Services. 2. Improve quality of MH/DD/SAS Services. 3. Improve outcomes for people receiving MH/DD/SAS Services. 4. Improve access to primary care for people with mental illness, developmental disabilities and substance abuse. 5. Improve cost benefit of services. 6. Effectively manage all public resources assigned to the MCOs. IMPLEMENTATION / Start Date Time lines….  Phase I PBH - AC – Oct. 2011; 5 Cty – Jan. 2012; OPC – Apr. 2012 WHN - January 2012 ECBH- April 2012  Phase II Smoky Mountain -July 2012 SHC-December 2012 Guilford County Merger January 1 st / Waiver of GC: April 1 st.  Phase III – Implementation completed by January / July 2013 Alliance (Durham/Wake) / CenterPoint / Eastpointe (BC/SER) / Partners (PW/CR/MHP) / *Mecklenburg / *CoastalCare (SEC/ OC) * reflects potentially a February 1 st start date. DHHS – assigns unassigned catchment areas – January 2013 DHHS Process to be finalized by July 2013. POST IMPLEMENTATION January / July 2013….

11. 11 What is a Medicaid Waiver Medicaid Waiver - 101  DMA (Medicaid) gets a 1915b/c waiver from CMS (Centers for Medicare & Medicaid)  The waivers allows DMA to let a managed care company (LME) run the Medicaid program for mh/sa/dd services in their counties.  Allows DMA to offer HCBS (habilitation)  “Mini Medicaid Program”  DMA monitors the LME-MCOs to make sure that they follow all Medicaid rules.  CMS monitors DMA

12. 12 Medicaid Waiver Goals  Improved Quality of Care  Increased Cost Benefit  Predictable Medicaid Costs  Combine the management of State/Medicaid Service Funds at the Community Level  Increased consistency, efficiency and economies of scale in the management of community services Support the purchase and delivery of best practice services  Ensure that services are managed and delivered within a quality management framework  Empower the LME-MCO to build partnerships with consumers, providers and community stakeholders with the goal of creating a more responsive system of community care.

13. 13 What does the LME-MCO do for Medicaid?  Enroll & monitor providers (statewide)  Call Center—Customer Support, expansion of STR  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 Care Management, OAH Hearings (Due Process)  Gap analysis/community development  CCNC collaboration

14. 14 Medicaid “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

15. 15 CCNC & LME-MCO Collaboration  CCNC = NC Health Home  LME-MCO is vital partner that supports Health Home  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  Care Coordination = health promotion = cost savings

16. 16 Provider Concerns in a 1915 b/c Waiver  Limited Provider Network  Care Coordination inside the MCO  LME rate negotiation capacity (Note: higher rates can be paid to address access concerns)  Expanded service authorization function  Loss of direct enrollment in State Medicaid Program (contract with LME)  Loss of State level cost reporting/cost finding  Inclusion in larger system of care (e.g. community ICF-MR facilities) Note: Some concerns can be addressed in the DMA and DMHDDSAS Waiver Contracts signed by the LME-MCO

17. 17 What else does DMA require of the LME – MCO ?  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, and two external vendors monitor the LME-MCO — monthly, quarterly, yearly (on all operations) EQRO Annual Review

18. 18 1915 b/c Waiver “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

19. 19 1915 b/c Waiver “At-Risk” Benefits “ 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)

20. 20 Waiver Supports Intensity Scale (SIS)  Approved by CMS for use in NC  SIS used for planning purposes (AAIDD)  Used to develop funding levels currently in the following States: OR, CO, LA, GA, WA, RI, & 2 Canadian provinces;  In process for development to use for purposes to determine funding levels: NC, UT, MA, ME, ND **CAP MR/DD services crosswalk to Innovations services = web posting…

21. 21 CCNC—NC Health Home  CCNC is the Health Home for NC Medicaid recipients.  CCNC is responsible for the following for patients with “chronic conditions*”:  Comprehensive care management  Care coordination/health promotion  Comprehensive transitional care  Patient and family support  Referrals to community and social support services  Use of HIT to link services *including serious/persistent mental illness and substance abuse disorders

22. 22 CCNC—NC Health Home Behavioral Health Initiatives  14 Psychiatrists in Regional Networks  Teach PCPs to address MH/SA issues in primary care  Teach PCPs to collaborate with behavioral health providers  Use brief screenings  Ex. Screening, Brief Intervention, and Referral to Treatment (SBIRT)  MDD education and treatment  Atypical antipsychotic programs for children  Training CCNC care managers and PCPs in Motivational Interviewing

23. 23 Health Homes and Specialty Behavioral Health  CCNC (Community Care of NC) will be NC’s Health Home Model with the LME/MCO to address the behavioral health needs through the 1915 b/c waiver  Much work has been done to interface the data sharing and to clarify the roles/responsibilities of LME/MCOs and CCNC  Four Quadrant Care Management Model  Determines who takes the lead in care management  Quadrants 1 and 3 – CCNC/Primary Care take lead  Quadrant 2 – LME/MCO/Behavioral Health take lead  Quadrant 4 – flexible sharing of responsibilities

24. 24 CCNC Four Quadrant Care Management Model Quadrant I:  Low MH/DD/SA health  Low physical health complexity/risk Quadrant II:  High MH/DD/SA health  Low physical health complexity/risk Quadrant III:  Low MH/DD/SA health  High physical health complexity/risk Quadrant IV:  High MH/DD/SA health  High physical health complexity/risk

25. 25 CCNC Health Homes & LME - MCOs  LME/MCOs provide care management for individuals with SPMI and substance use “chronic conditions”  LME/MCOs formed a collaborative relationship with local CCNC networks  LME/MCOs signed data-sharing agreements with the CCNC Informatics Center

26. 26 Waiver Strategic Plan Report  The Waiver Strategic Plan Report is an initial guide to monitor LME/MCO waiver implementation and takes us through the dates of January 2013.  The report is considered an initial plan that will evolve and be modified over time, experience, and with LME and stakeholder involvement.  The Department through DMH/DD/SAS and DMA will monitor, evaluate and report the progress quarterly per legislative requirements. Web link to the report…. http://www.ncdhhs.gov/mhddsas/providers/1915bcWaiver/ waiver1915b-cplan-final10-19-11.pdf

27. 27 Waiver Strategic Introduction – Continued: GOALS: 1. Improve access to MH/DD/SAS Services. 2. Improve quality of MH/DD/SAS Services. 3. Improve outcomes for people receiving MH/DD/SAS Services. 4. Improve access to primary care for people with mental illness, developmental disabilities and substance abuse. 5. Improve cost benefit of services. 6. Effectively manage all public resources assigned to the MCOs. The Strategic Implementation Plan:  Is organized around a framework encompassing the State’s vision for the Waiver initiative and goals.  Is based on an assessment of strengths and the challenges that lie ahead.  Will provide a vehicle for active communication with all stakeholders across the State and for coordinating detailed implementation tasks among the Department, DMA, DMH/DD/SAS, LMEs, providers and consumers, and family members.

28. 28 Pre-Implementation Plan Process for LMEs GOALS: 1. Improve access to MH/DD/SAS Services. 2. Improve quality of MH/DD/SAS Services. 3. Improve outcomes for people receiving MH/DD/SAS Services. 4. Improve access to primary care for people with mental illness, developmental disabilities and substance abuse. 5. Improve cost benefit of services. 6. Effectively manage all public resources assigned to the MCOs.  PRE – Implementation Monitoring Phase of LME-MCOs reporting out on their implementation activities  IMT’s (Intra-Departmental Monitoring Team)  Agenda: Report out of all of the LME-MCO function areas of development…  Aggregate IMTs /// Think Tank IMTs  Two Readiness reviews State & Contract Agent  CMS Approval.  The DHHS Executive Monitoring Team (EMT) including representatives from multiple stakeholder groups provided review and feedback

29. 29 Post-Implementation Process for LME-MCOs GOALS: 1. Improve access to MH/DD/SAS Services. 2. Improve quality of MH/DD/SAS Services. 3. Improve outcomes for people receiving MH/DD/SAS Services. 4. Improve access to primary care for people with mental illness, developmental disabilities and substance abuse. 5. Improve cost benefit of services. 6. Effectively manage all public resources assigned to the MCOs.  POST - Implementation Phase IMT  EQRO – DMA vendor goes to the LME.  6 months of on-going monthly monitoring IMTs  Annual Reviews  Positive  Improvement  POC  Industry Standard Recommendations…. EBP Services  Feedback built into a plan of correction  Quarterly IMTs  EMT

30. 30 Evaluation Process, Continued: Additional mechanisms to evaluate the Waiver implementation process and ensure the quality of the service system, include, but are not limited to: External Quality Review (EQR) Intra-departmental Monitoring Teams (IMTs) Annual On-site Reviews Performance Measures Executive Management Team (EMT) Global Continuous Quality Improvement DMH/DD/SAS Quality Improvement Steering Committee The REAL Start Date: Jan 1, 2013 CQI Date: On- going !

31. 31 “Responsible Change to Achieve Easy Access, Better Quality and Personal Outcomes” The LME-MCOs managing the 1915 b/c Waivers will continue to evolve and be modified over time with continued stakeholder involvement striving for quality and improvement of the mh/dd/sas system. WAIVER GOALS: 1. Improve access to MH/DD/SAS Services. 2. Improve quality of MH/DD/SAS Services. 3. Improve outcomes for people receiving MH/DD/SAS Services. 4. Improve access to primary care for people with mental illness, developmental disabilities and substance abuse. 5. Improve cost benefit of services. 6. Effectively manage all public resources assigned to the MCOs.

32. 32 Thank you… Questions / Thoughts / Comments….