OPC and Waiver Expansion
Frequently Asked Questions
U=
pdated
information added in
1.
OPC
is currently talking to PBH about the possibility of joining them.
At their regularly scheduled meeting on=
April
14th the OPC Area Board reviewed the Request for Application (RFA) that was=
recently
released by the Department of Health & Human Services (DHHS) related to=
the
expansion of the 1915(b)(c) waiver.
After extensive discussion the OPC Board voted unanimously to move
forward in negotiations with PBH and to seek authorization from the Boards =
of
Commissioners in Orange, Person & Chatham counties to do so.
On
April 18, 2011 the Chatham County Board of County Commissioners reviewed and
voted unanimously to support OPC moving forward with PBH.
On
April 18, 2011 the Person County Board of County Commissioners reviewed and
voted unanimously to support OPC moving forward with PBH.
On
April 21, 2011 the Consumer & Family Advisory Committee for OPC Area
Program met with management staff, reviewed specifics regarding the Request=
for
Application, and after extensive discussion made the decision to support OPC
moving forward with PBH.
On
May 17, 2011 the Orange County Board of County Commissioners reviewed and v=
oted
unanimously to support OPC moving forward with PBH.
2.
PBH
is an LME like OPC. They currently
operate a Medicaid waiver and have asked us to partner with them.
PBH is a Local Management Entity (LME) =
like
OPC which covers Cabarrus, Davidson, Rowan, Stanly & Union counties.
In February 2010 OPC was approached by =
PBH
about the possibility of forming an alliance.
With approval of the OPC Area Board negotiations were initiated. In June 2010 legislation was passed whi=
ch
restricted PBH from expanding their geographic region and limited the numbe=
r of
sites for expansion of the Medicaid waiver.
OPC’s negotiations with PBH were put on hold. Legislative support now exists for remo=
val of
the restrictions on PBH, as well as expansion of the waiver.
3.
Under
proposed legislation, OPC is currently not large enough to operate as we
currently exist.
The number of LMEs in the state has been
reduced over the years from 41 to 23. Given
the current economic climate, LMEs have been encouraged to continue
consolidation efforts in order to create efficiencies and savings. OPC is the fourth smallest LME in the s=
tate
based on the population of our three counties (227,963), so with the recent
release of the RFA and related legislation, it is no longer an option for O=
PC
to remain “as is”. The minimum
population threshold for LMEs will be increased to 300,000 by 7/1/12 and
500,000 by 7/1/13, and the number of LMEs in the state will be reduced to
8-10. While we are very proud of O=
PC and
its accomplishments over the last 40+ years, we recognize that we will need=
to
change, and we have tried to be thoughtful and proactive in considering our
future options.
4.
Yes,
although we may look a little different in the future.
We are currently in discussions with PBH
about what the local presence in the OPC community will look like. OPC will most definitely still exist an=
d will
be available to respond to the needs of the local community, although our
internal structure may look different than it does currently.
5.
A waiver
is an agreement between the state and Center for Medicaid Services in
Washington to be released from certain Medicaid rules.
In 1965, amendments to the Social Secur= ity Act (SSA) established the Medicaid program. Under the Medicaid program each state establishes its own eligibility standards, benefits packages, payment rates, and program administration. Th= ere are two major types of serviced delivery systems in Medicaid; fee for servi= ce and managed care. States wishing to operate managed care service delivery systems must apply for a waiver of certain Medicaid rules. The Social Secur= ity Act authorizes multiple waiver and demonstration authorities which allows f= or flexibility at the state level. Un= der Section 1915 (b) of the SSA, w= aivers are granted which allow states to implement managed care delivery systems a= nd restrict consumer choice of providers. These specific waivers often target individuals with mental health a= nd substance abuse issues, although some services are available for people with intellectual/developmental disabilities (I/DD). Under Section 1915(c) of the SSA, waivers exist= to provide a continuum of services in the community to individuals who are disabled. Presently North Carolina operates a 1915 (c) waiver for individuals with I/DD referred to as the CAP-MR/DD program. States may choose to simultaneously operate 1915 (b) and= (c) waivers.
Medicaid= waivers are used to improve access to and quality of services and manage cost. Entities that operate waivers are gener= ally referred to as Managed Care Organizations (MCO). NC has chosen to operate i= ts waiver through a single prepaid inpatient health plan (PIHP). PIHPs are man= aged care organizations that provide, arrange for or otherwise have the responsibility for the provision of specialty care (including inpatient and institutional) for individuals with MH/DD/SAS needs. PBH currently operates= a PIHP and is the only combined 1915(b)(c) waiver in North Carolina. North Ca= rolina has obtained approval from the Centers for Medicare and Medicaid Services (= CMS) to transition the entire state to a combined 1915 (b)(c) waiver replicating= the PBH model statewide.
For more information about waivers, ple=
ase
see the waiver section on the OPC website, www.opcareaprogram.com
6.
We
think it is the right thing to do.
OPC supports the concept of managing ca=
re to
assure that all individuals receive appropriate services, and we strongly
support the concept of public management of the behavioral healthcare syste=
m.
7.
Some
people are worried about what this change will mean for providers and
consumers.
Expanding the waiver statewide is a big
change for North Carolina, and as with any change of this magnitude, there =
is
some anxiety about what it all means.
Some advocacy groups, particularly those representing the interests =
of
individuals with I/DD, have been very vocal about their concerns for that
population in a waiver environment. While
it is true that care for these individuals (as well as individuals with men=
tal
health and substance use disorders) will be managed differently in the futu=
re, PBH,
as well as other states, have successfully operated waivers that appropriat=
ely
serve all disabilities. An article by the National Leadership Consortium on
Developmental Disabilities that looked at the experiences of four states co=
ncludes…
Smith and Ashbaugh, in a groundbreaking 1995 ana=
lysis
of potential applications of managed care within the developmental disabili=
ties
services sector, wrote: “Whatever
mistrust there might be about managed care has to be balanced against its
trinity of promises: lower costs, better access, and higher quality. Curbing
Medicaid payments to the states means developmental disabilities systems wi=
ll
face a far different fiscal landscape in the foreseeable future than has be=
en
true over the past decade. This altered [low growth] fiscal landscape has
enormous implications for the health and vitality of these systems and even
more profound implications for the people and families who depend on these
systems for supports. In this vein, dismissing managed care makes no sense.=
DD
service systems will need to take advantage of every tool available in orde=
r to
survive and be responsive to the people they support.” These words were
written at a time when Congress appeared to be on the brink of imposing an
across-the-board cap on federal Medicaid spending. Today, our nation is rap=
idly
approaching another crisis in financing not only of Medicaid services but of
other major social entitlement programs as well (e.g., Medicare; Social
Security, SSI, Food Stamps, etc.). Given the circumstances, Smith and
Ashbaugh’s admonition to consider all of the “arrows in our quiver” seems as
relevant today as it was thirteen years ago. And, as unsettling as it may s=
eem,
managed care is one of those arrows.
For
access to the full article referenced above as well as information about
waivers from several advocacy groups, please see the waiver section on the =
OPC
website, www.opcareaprogram.com
8.
In
general, most services should remain the same, although who approves them w=
ill
change.
Expansion of the waiver should be a fai=
rly
seamless process for consumers. It=
should
result in greater consistency across the state in the services that are
provided, in how services are accessed, and in expectations and requirements
for providers. If savings are real=
ized,
they can be put toward creative, innovative services that may not be typica=
l Medicaid
reimbursable services. The biggest change will be that Medicaid services wi=
ll
no longer be authorized by the state’s current vendor, Value Options, but
instead will be authorized by the LME. How
case management is provided may also change for some consumers (see questio=
n #12)
9.
As
much as possible, OPC will work to help consumers keep their current provid=
er
if they so desire.
As
indicated in the 1915 (b) waiver amendment (http://www.ncdhhs.gov/mhddsas/waiver/20=
11/section1915-bwaiver-renewal11-13.pdf) “Enrollees will have free choice of
providers within the prepaid inpatient health plan (PIHP) and may change
providers as often as desired. If an individual joins the PIHP and is alrea=
dy
established with a provider who is not a member of the network, the PIHPs w=
ill
make every effort to arrange for the consumer to continue with the same
provider if the consumer so desires. In this case, the provider would be
required to meet the same qualifications as other providers in the network.=
In
addition, if an enrollee needs a specialized service that is not available
through the network, the PIHP will arrange for the service to be provided
outside the network if a qualified provider is available. Finally, except in
certain situations, enrollees will be given the choice between at least two
providers. Exceptions would involve institutional services or highly-specia=
lized
services which are usually available through only one facility or agency in=
the
geographic area.”
10.<=
span
style=3D'font:7.0pt "Times New Roman"'> =
Under
the waiver will OPC serve all the consumers that are currently being served
without a cut in any services?
We
don’t know. In addition to changes=
that
will be created by the waiver, we also anticipate cuts to the rates paid for
services. It is hard to say what i=
mpact
those cuts will have on services.
To answer yes to this question would as=
sume
that all current treatment plans match the needs of all individuals, which =
we
do not believe has been proven to be the case when records have been
audited. In a managed care enviro=
nment
you assess needs at the individual level and create treatment plans that are
responsive to those needs within a very formal framework. To answer yes to this question would al=
so
assume that the resources currently available would remain so without
change. As we are all well aware, =
North
Carolina is facing a serious fiscal shortfall.
We are expecting budget reductions at the administrative level and
possibly at the service level. Med=
icaid
& Medicare rate reductions are already being rolled out, so the service
system will likely face changes unrelated to implementation of the 1915(b)(=
c)
waiver.
11.<=
span
style=3D'font:7.0pt "Times New Roman"'> =
What
will happen to OPC providers?
As
much as possible, OPC will work to keep our current provider network.
One of the rules that is waived under a
1915(b) waiver is freedom of choice.
That means waiver sites can have a closed provider network, limiting=
it
to those providers with good outcomes.
OPC has been fortunate to have a long-standing relationship with many
excellent providers in our community, and that should not change. In fact, PBH has recommended to LMEs
interested in becoming waiver sites that current providers be included when=
the
waiver is opened in the LME’s community.
If a provider then subsequently is not performing, they would be rem=
oved
from the network.
12.<=
span
style=3D'font:7.0pt "Times New Roman"'> =
Who
is going to do case management?
Based
on the latest information we have received, it appears that LMEs will do ca=
re
management and coordination.
According to the latest waiver fact she=
et
published by the Division of MH/DD/SAS (http://www.ncdhhs.gov/mhddsas/factsheet=
s/1915bcwaiverddfactsheet4-11.pdf), targeted case management will not be=
a
stand-alone service for any disability group under the waiver. The functions of care management and
coordination will be performed by the LME. However, individuals with Intell=
ectual/Developmental
Disabilities (I/DD) may receive a different type of direct service, called
Community Guide, from provider agencies.
13.<=
span
style=3D'font:7.0pt "Times New Roman"'> =
Will
OPC have any type of forums to educate the community about what is going on=
?
Absolutely!
We are currently working on a strategic=
plan
for educating the community about the waiver and will be publishing details=
as
soon as we have them.
The first articles regarding waiver expansion began running =
in
local newspapers on May 18, 2011.
Public forums have been scheduled for the following dates &a=
mp;
locations.
ORANGE COUNTY
June 15, 2011 6:00pm-8:00pm
Location: Sunrise
Church
1315 New Hope Trace
Chapel Hill, NC 27516
PERSON COUNTY
June 29, 2011 6:00 p.m.-8:00p.m.
Location: Piedmont
Community College Auditorium (D101)
1715 College Dr.
Roxboro, NC 27573
CHATHAM COUNTY
June 22, 2011 6:00-8:00p.m.
Location: Chatham =
County
Agriculture Auditorium
45 South St
Pittsboro, NC 27312
14.<=
span
style=3D'font:7.0pt "Times New Roman"'> =
Are
the counties going to be at risk if the waiver loses money?
It
is our understanding that the counties will not be at risk.
In a waiver the “risk” (of losing money=
) is
transferred from the state to the LME, which serves as a Managed Care
Organization (MCO). The waiver requires the MCO to have an adequate risk
reserve. Concerns have been expres=
sed
about the counties’ responsibilities if the LME overspends. It is our
understanding that the Institute of Government has researched this issue and
provided information which would not support the assertion that the
counties would be at risk in a waiver setting.
Also, Secretary Cansler reported on April 5th that there was
consideration being given to either new or revised legislation which would
assure that counties would not be at “risk” in a waiver setting.
15.<=
span
style=3D'font:7.0pt "Times New Roman"'> =
Will
money be taken away from developmental disability services and given to men=
tal
health and substance abuse services?
We
have no reason to believe that this would happen.
We are aware that there is concern that
developmental disability funding will be used to serve other disability are=
as
in a waiver setting. We are also a=
ware,
however, that this is the same argument that was made when area authorities
were shifted to a single stream funding model.
We have no information to suggest that has ever occurred in a progra=
m with
single stream funding; no evidence to suggest that it has occurred at PBH; =
and
no reason to believe that it would occur in any new waiver site.
16.<=
span
style=3D'font:7.0pt "Times New Roman"'> =
Where
can I find more information about waivers?
OPC has created a section on our webpag=
e that
contains links to resources as well as various documents that have been wri=
tten
about waivers. You can access our =
site
at www.opcareaprogram.com
17.<=
span
style=3D'font:7.0pt "Times New Roman"'> =
Who
can I call if I have questions?
If you have questions, you can contact =
OPC’s
customer service line at (888)277-2303 or (919)913-4120 or you may e-mail y=
our
questions directly to waiverquestions@opc-mhc.org<=
span
style=3D'mso-bidi-font-size:12.0pt'> We will be posting the questions and a=
nswers
and will be updating this FAQ document on a regular basis. The Division of MH/DD/SAS is also respo=
nding
to questions sent to: 1915BC.Waiver.Contact@dhhs.nc.gov
18. =
How
will the Managed Care Waiver affect eligibility for Medicaid for minor chil=
dren
whose family income exceeds limit to qualify for Medicaid? Currently, those with CAP have Medicaid=
based
only on their own income, even though they are minor children. For those who do not have CAP and family
income exceeds limit is there a path to having Medicaid coverage? I have had these concerns raised, and my
sense of it from the PBH site is that everyone that qualifies for services
under the Managed Care Waiver will be treated as CAP individuals are now for
Medicaid coverage. Is that in fac=
t the
case?
The expansion of the 1915 (b) (c) waive=
r does
not modify the current Medicaid eligibility criteria.
On
page 10 of the 1915(c) HCBS Waiver Amendment dated 4-1-11; it states that
minors will be considered as a family of one for financial eligibility for =
the
Innovations Waiver.
Individuals
who are currently CAP-MR/DD waiver participants will crosswalk to the
Innovations Waiver as specified on
page 19 of the 1915(c) HCBS Waiver Amendment dated 4-1-11: “To ensure the smooth transition of
individuals from the current CAP-MR/DD waiver(s) to the NC Innovations Waiv=
er,
the eligibility determination of all current CAP-MR/DD recipients will be
accepted in the NC Innovations Waiver until the next annual re-evaluation of
eligibility at the birth month. Likewise, the Person Centered Plan (Plan of
Care) will be accepted in the NC Innovations Waiver until the next annual I=
SP
plan development at the birth month.”
19. =
Will the Supports Intensity Scale™ (SIS)
replace the NC-SNAP?
Yes, as the waiver is expanded into eac=
h new
LME the SIS will be administered to all individuals with I/DD participating=
in
the waiver and will replace the NC SNAP.
20. =
Will Person County have fewer resources or less of a voice in
decisions as a result of the merger/waiver?
We do not anticipate that
Person County will have fewer resources or less say than it has now as a re=
sult
of a merger between OPC and PBH. The governance structure for the new entity
has not been determined as of this date, neither has the actual number of
representatives from each county.
Federal rules exist which
require waiver entities to complete consumer and provider satisfaction surv=
eys
on the service system and waiver entity operation.
21. =
How is PBH’s Care Review structured? Initial reviews? Reviews of children in placement? Who
staffs? What is the connection of =
care
review to Utilization Management? =
PBH has a Care Review Tea=
m that
reviews out of home child placements that meet certain criteria.
See link http://www.pbhsolutions.org/SOC and click on the icon “Click here to view the Care Team Poli=
cies
& Procedures” for full details about the Care Review process; when revi=
ews
should occur; and the connection between Utilization Management and Care
Review.
22. =
Right now, when a child is adopted through a Department of S=
ocial
Services, their Medicaid will always be from the county of that adoption ev=
en
when their adoptive parents move to other counties. Currently, the LME of the county of the=
ir
adoptive parent's residence does the care review no matter the county of th=
eir
Medicaid. Will this stay the same =
when
there is a statewide waiver?
Medicaid eligibility rule=
s do
not change with the waiver; therefore we do not anticipate any change in as=
signing
Medicaid county when adoption is involved. Given that each entity operating=
the
waiver may have different utilization management criteria, the LME where the
Medicaid originates will be responsible for Utilization Management and Care
Review. PBH will conduct reviews on each child with Medicaid from all count=
ies
included in the PBH waiver.
23. =
Does PBH have Child Collaborative committees and if so, what
role do they play? Will the Child
Collaborative continue to have a voice in the use of child non-UCR funds and
the selection of child mental health/substance abuse priorities? If not, where does input from our commu=
nity stakeholders
come from in terms of the use of IPRS and county dollars?
PBH has local Community
Collaboratives that, among other things, makes recommendations to PBH regar=
ding
state funding and what services the collaborative would like to see provide=
d in
the community. We anticipate collaboratives will continue to have a voice in
the use of child funds (both UCR a=
nd
Non-UCR) by helping OPC to set priorities and identify uses for the funds. =
PBH’s Child Collaborative is made up of PBH staff,
parents, providers and community agency partners including schools, Departm=
ent(s)
of Juvenile Justice, and Department(s) of Social Services. The collaborativ=
es
exist in each county and meet on a regular basis. The collaboratives have b=
ylaws,
set goals, monitor child residential data, oversee the functioning of Care
Review teams and make recommendations to PBH regarding state funding and wh=
at
services the collaborative would like to see provided in the community. More
information on the PBH Child Collaboratives can be obtained at http://www.pbhsolutions.org/SOC by selecting the SOC
Collaborative icon.
24. =
Are there any residential services covered by the (b) waiver=
and
reimbursed by Medicaid?
All services available in=
the
NC Medicaid State Plan must be covered in the 1915 b waiver. This is true f=
or
residential services. See DMA’s website for the NC State Plan at http://www.ncdhhs.gov/dma/plan/index.htm.
In addition to regular state plan services, respite (as a pa=
rt
of the (b3) provision in the 1915 b waiver) is available to children and ad=
ults
who meet certain criteria. Also un=
der
1915 (b3) some residential supports are available to certain children and
adults who are functionally eligible for, but not enrolled in NC Innovation=
s 1915(c
) waiver program, if they are exiting ICF-MRs.
25. =
What child mental health crisis services currently exist in =
the (b)
waiver?
All services available in=
the
NC Medicaid State Plan must be covered in the 1915(b) waiver. This is true =
for crisis
services. Therefore inpatient
hospitalization, PRTF and mobile crisis services are available to children =
as
well as first responder capacity within enhanced services such as Intensive
In-Home and Multisystemic Therapy. =
See DMA’s website for the=
NC
Medicaid State Plan at <=
span
style=3D'mso-bidi-font-size:12.0pt;color:blue'>http://www.ncdhhs.gov/dma/pl=
an/index.htm.
Additionally, under 1915(=
b3)
respite is available to children ages 3-21 who are not functionally eligible
for the NC Innovations waiver program, but require continuous supervision d=
ue
to a mental health (Axis I or II) diagnosis (CALOCUS level III or greater) =
or
substance abuse diagnosis (American Society of Addiction Medicine (ASAM)
criteria of II.1 or greater). There are no other “crisis” residential servi=
ces
funded by the waiver. However some=
Non
UCR funded crisis services such as Rapid Response may also still exist in t=
he
OPC area.
26. =
Does PBH have the right to choose which provider agency they=
contract
with; or since OPC is merging with PBH do all agencies automatically go und=
er
PBH LME?
A 1915 (b) Freedom of Cho=
ice
waiver does allow PBH to choose which providers are included in their netwo=
rk
of providers. If OPC merges with PBH, it is both agencies’ intention to
continue to contract with existing providers whose contract is in good stan=
ding
with OPC.
27. =
What is the relationship between the (b) and (c) waivers?
The 1915(b) (c) are concu=
rrent
waivers that are described by PBH as “one waiver system”. The 1915(b) waiver
(including b3) includes services for all disability groups, mental
health/developmental disability/ and substance abuse; while the 1915(c) wai=
ver
includes services only for individuals with intellectual/developmental
disabilities. Operating the (b) (c) waivers concurrently allows NC to devel=
op a
more complete range of services and supports for people in the community and
creates additional services by using money generated from savings by
effectively managing the service system.
PBH’s Consumer and Family
Member Handbook further indicates that “The concurrent waivers are used to
implement a mandatory managed care program that includes Home and Community
Based Services (HCBS) in the managed care contract. The 1915 (c) waiver all=
ows
a state to target eligibility and provide the HCBS services. The 1915(b) wa=
iver
then allows a state to mandate enrollment in managed care plans that provide
these HCBS services.