Question =	Response
*Why hasn’t there been more stakeholder feedback about expanding the managed care waivers?*	*There have been ongoing conversations* among providers, LMEs, advocacy organizations and other stakeholders, state lea= ders in the Department, DMA, and DMH/DD/SA as well as members of the General Assembly. The Department = has been engaged in ongoing dialogue with the State Consumer Family Advisory = Committee. The goal of exp= anding the Medicaid waivers is not new. *It has been* *standing DHHS policy for several year=* s and has been discussed in m= any forums over this period of time. Over the past s= everal years, waiver expansion has been reviewed extensively by the Legislative Oversight Committee for MH/DD/SA. The proposed legislation includes a requirement for ongoing dialogue among stakeholder= s at each LME waiver site.
*Is Managed Care bad for people with intellectual and developmental disabilities?*	*No.* The 1915 c waiver for people with intellectual and developmental disabilities is a separate waiver for developmental disabilities that operates under the managed care umbrella. The 1915 c waiver has unique ser= vices that are specially designed for people with intellectual and developmental disabilities, just like the CAP-MR/DD waiver. 1915 c waiver recipients have the same access and entitlement to medically necessary services that they would have outside of Managed Care.<= /p>
*Does the Managed Care waiver expect that people will Recover?*	*No.* *Many mental health and substance abuse conditions are lifelong disabilities.* The= term “Recovery” means that consumers have reached a point that they can manage their illness, much in the way that a person with a chronic illness, such as diabetes, can reach a point where the illness is under control with medication and life style changes.
*Does Recovery apply to people with intellectual and developmental disabilities?*	*No.* People with intellectual and developmental disabilities also have lifelong conditions that change over time, with variable levels of improvement. While “Recovery” is a concept important to people with mental health and substance abuse conditions, the concepts valuable to people with intellectual and developmental disabilities are *self determination and empowerment.* These principles ref= erence the value and importance of the person in defining personal priorities and making their own decisions and *are integral to the design of the Innovations Waiver.* =
*What are the safeguards for consumers under Managed Care?*	Consumers can <= /span>*file ap= peals* if they disagree with decisi= ons made about the type or amount of services that are authorized for their c= are. *This process is strictly managed according to Federal regulations.<= /span>* All LME waiver = sites will be required to maintain an extensive grievance tracking system which= will be monitored by the Division of Medical Assistance. Consumers can also directly cont= act the Division of Medical Assistance.
*What is a Closed Provider Network?*	Managed care al= lows the managed care organization to limit the size of their provider network. However, *access to care must be ensured. An extensive provider capacity analysis as well as geographic acce= ss must be documented by the managed care organization. The advantage o= f a Closed Network is that is allows the managed care organization to “right size” the network.&nb= sp; The goal is to have enough providers for competition and choice, b= ut not so many that no provider has adequate market share. Without adequate market share, provi= ders do not have enough funding to invest in the quality systems* that = are needed to operate in a waiver environmen= t. PBH accepted all providers when their waiver first began, and then adjusted the size of the network over time. No provi= der that was meeting quality and performance standards was eliminated from the PBH network in order to achieve the closed network. Currently PBH has 277 providers= , 100 of these provide services to people with developmental disabilities. =
Why will case management go away under the Managed Care Waiver?	The managed care organization must meet extensive accountability standards, data reporting requirements, and must exercise risk management responsibilities that can= not be assured through the service Targeted Case Management. Mental Health a= nd Substance Abuse: *Targete= d Case management cannot be provided to individuals that receive Enhanced Servic= es.* Case management is included in t= he service definitions for Enhanced Services. Consumers receiving basic servic= es such as outpatient therapy should not need Targeted Case Management. For the DD waiv= er, the assessment process, development of the individual service plan, and monit= oring for the 1915 (c) waiver are data intensive, outcomes focused and highly t= echnical responsibilities. A high le= vel of consistency is essential and would be impossible to achieve if it were decentralized across multiple providers.
*How will advocacy be provided for people with intellectual and developmental disabilities?*	The *federal service definition for Targeted Case Management does not include advocacy=* or other social supports for= the individual. It is strictly focused on assessment, service plan development, service linkage and monitoring. No other activi= ties are covered. The Innovations waiver includes a service called *Community Guide* which *includes advocacy,* assistance in accessing the community, and other supports.
*Doesn’t North Carolina have Independent Case Management?*	*No.* North Carolina has a few provide= rs that ONLY provide case management. But most providers offer many other services. Providers are not allowed to off= er services to a consumer for whom they provide case management. The concern is = that Targeted Case Management requires providers to monitor the care and servi= ces provided by other providers. Providers frequently monitor one another because many providers offer both targeted case management and services to people with developmental disabilities. Providers of Targeted Case Manag= ement have the responsibility of *reporting quality and compliance iss= ues found in other provider settings.* This can cause resentment and animosity among providers that monitor one another. This also raises the concern that problems in consumer care may be under-reported. Under Managed C= are, *LMEs are fully accountable for quality and compliance and cannot rely on provi= ders to monitor the care provided to consumers by other providers.*
*We heard that the rate for Community Guide is very low.*	The rate for Community Guide is *$36 per hour*. Community Guide Staff are n= ot required to be Qualified Professionals. This rate is similar to that of o= ther similar services. However, = LMEs can set their own rates for services.&nb= sp; Providers should communicate with LMEs about rates.
*How will CABHAs be impacted by the loss of case management?<= /o:p>*	The Enhanced Se= rvices for people with mental health and substance abuse conditions have case management functions included i= n the service definition. The= refore, Targeted Case Management would be a duplication and therefore not allowed<= /i>. *Most CABHAs report that they are not able to bill enough Targeted Case Managem= ent* to cover their costs. Under waivers, = CABHAs will continue to serve as the cornerstone of the community system for peo= ple with mental health and substance abuse conditions. This clinical infrastructure is essential for a successful community system.= *Another method will be developed to pay CABHAs for their clinical infrastructure.=*
*What is Care Coordination?*	Care Coordinati= on is a managed care function that is designed to serve high need individuals, = it is outcome focused, and is guided by the responsibilities of the managed = care organization to ensure that vulnerable populations have access to needed care. Care Coordinators are community based and provide hands on assistance to individuals. *Care coordination is not a service. It is a more cost effective and outcomes driven tool* used in managed care and insurance systems, simila= r to the model used in Community Care of North Carolina.
*How will the Person Centered Plan be developed?*	Providers of En= hanced Services develop the person centered plan for the people they serve.= Providers of ba= sic services develop a treatment plan that reflects goals and strategies but a person centered plan is not required. For people with intellectual and developmental disabilities, the Care Coordinator serves = as technical advisor to the individual’s team, and develops an integra= ted person centered plan which is implemented across providers, and is based = on priorities, preferences and goals established in the team meeting.
*What is the 1915 (i) Option?&nbs= p;*	The 1915 (i) Op= tion allows states to add services to the state Medicaid plan that are similar= to services that are offered under 1915 c waivers. Services for people with Intelle= ctual and Developmental Disabilities could be added to the state Medicaid Plan.= The advantage f= or states is that they *can add waiver-like services to the state Medicaid plan, but they do not have to develop a 1915 c wavier to accompl= ish this.*
*Is the 1915 (i) Option an entitlement like other Medicaid service= s?*	*Yes.* If services for people with Intellectual and Developmental Disabilities were added to the state Medicaid Plan using the 1915 (i) Option, an entitlement would be created for people with Intellectual and Developmental Disabilit= ies that already have Medicaid. 1915 c waiver programs like CAP-MR/DD and Innovations waivers for people with intellect= ual and developmental disabilities are not entitlements. The state is limited= to serving a certain number of people each year.
*What are the risks of adding services under the 1915 (i) option to the state Medicaid Plan?*	If the state ad= ds services under the 1915 (i) option before the Managed Care Waiver is expanded statewide, there is a *risk of escalating costs that cannot be managed*. However, the DH= HS recognizes the importance of the 1915 (i) Option and has agreed to meet w= ith stakeholders to discuss and consider adding services for people with developmental disabilities to the state Medicaid Plan using the 1915 (i) Option at some future point.
*Can North Carolina have both the 1915 (i) option and Managed Care= ?*	*Yes.* If services for people with Intellectual and Developmental Disabilities were added to the state Medic= aid Plan under the 1915 (i) the services would likely fall under Managed C= are just like the rest of the services in the state Medicaid Plan (such as Inpatient, Outpatient, Community Support Team, etc).
*Is the 1915 (i) option good for people with intellectual and developmental disabilities?*	This option *creates= new services that would become an entitlement* for people with Intellectual= and Developmental Disabilities who already have Medicaid. There are speci= alized services designed for people with Mental Health and Substance Abuse conditions in the state plan. Prior to the 1915 (i) Option, states were not able to add specialized services = for people with developmental disabilities to the state Medicaid Plan. Adding services for people with intellectual= and developmental disabilities to the state Medicaid Plan would be one way to= establish parity with other disability groups that are currently eligible for Medic= aid.
*Why should the PBH LME be allowed to expand?*	PBH expansion <= /span>*will he= lp the state expand the waiver to LMEs that are too small to qualify to operate = the waiver on their own. <= /o:p>* Regional manage= ment is one way to reduce management costs, thus making more funds available f= or services. Because managed care is an insurance model, the risk is reduced with a larger population. Like all LMEs planning to operate Managed Care waivers, PBH intends to maintain a local presence in areas not contiguous to their catchment area.
*Are there outcomes for the PBH waivers?*=	There have been extensive evaluations of the PBH waiver, including evaluation of the DD waiver. PBH has consist= ently received positive reviews across all disability areas.<= /p> Detailed report= s are available if requested.
*Has the PBH LME shown cost savings?*	PBH has realize= d *signifi= cant cost savings across all disability areas.&nbs= p;* Data show that = PBH costs for the DD waiver operated by PBH are significantly less than the c= ost for the CAP-MR/DD waiver.
*What is the Supports Intensity Scale?*	The Supports Intensity Scale is a nationally regarded, standardized, reliable and valid measure of the intensity of need for supports. This assessment is not focused o= n a person’s disability, it is focused on the support needs of the individual. An individual&#= 8217;s support needs will vary according the nature and extent of their disabili= ty as well as by the amount of support available from the person’s fam= ily and friends. Evaluators are trained by Master trainers in order to ensure consistency and integrity of evaluation results.
*What is the Support Needs Matrix?*	This is a matri= x that *aligns the support needs of a person with developmental disabilities, with the appropriate amount of funding. This system will ensure that peo= ple with similar needs receive similar amounts of services. <= /o:p> The SIS eval= uation findings are used in the Support Needs Matrix to measure each person̵= 7;s need against all persons in that LME. In this way, funding can be allocat= ed fairly and equitably to address each individuals needs and preferences. Studies of PBH = waiver participants as well as a state sample of consumers receiving services un= der the CAP-MR/DD waiver reveal that there is no correlation between a person’s level of need and the amount of funding received. This is unacceptable in any service system. Evaluation find= ings at PBH show that about 25% of people served are receiving services that exce= ed their needs. The goal is that consumers receive the services and supports they need, no mo= re, no less AND that there is consistency in how funding is allocated = to individuals.*