Division of Medical Assistance (DMA) Updates

2012 Annual Housing ConferenceSeptember 27, 2012

Tara LarsonChief Clinical Operating Officer/Deputy Director

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What is Medicaid Today• Title XIX of the Social Security Act (Medicaid) is a

federal entitlement program that pays for medical assistance for certain individuals with low income and resources.

• Funding is made up of dollars from the federal government and state resources.

• It is very complex and has many, many rules and guidelines

• The federal agency that administers Medicaid is CMS – The Center for Medicaid and Medicare Services

• Medicaid and Medicare are not the same.

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• The federal government establishes very broad rules and then allows each state to:– Establish its own eligibility standards– Determine type, amount, duration and scope of service (what,

how much and what conditions)– Set the rate and payment for the services– Administer the program

• As a result, a person who is eligible in one state may not be eligible in another or services offered in one state are not the same in another state.

• As part of the broad rules, the federal government must approve what a state pays for, how a person is determined to be eligible, how rates are set and other aspects of the administration of the program. – SPAs– Waivers– Option Applications– Demonstration Projects

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WHAT IS COVERED TODAY by WHAT IS COVERED TODAY by

MedicaidMedicaid??• Ambulance• Children’s Dental• Durable Medical Equipment• Family Planning• Early Periodic Diagnosis

Screening and Treatment (EPDST)

• Children’s Hearing Aids• Clinics• Home Health• Hospital Services• Midwife and Nurse

Practitioner• Nursing Facility• Other Lab and X-ray• Physician• Psychiatric Residential

Treatment Facilities (PRTFS)• Routine Eye Examinations and

Visual Aids for Children

• Case Management• Chiropractor• Podiatry• CAP Programs• Adult Dental and Dentures• HMO Membership• Home Infusion Therapy• Hospice• ICF-MR• Mental Health• Personal Care• Orthotics and Prosthetics• Prescription Drugs• PT, OT and Speech Therapy• Private Duty Nursing• Respiratory Therapy• Transportation

Mandatory Services

Optional Services

Overview of Health Reform

• By January 1, 2014, the bill requires most people to have health insurance and most employers to provide affordable health insurance or pay a penalty.– Most low-income people will be eligible for Medicaid.– Most low- and moderate-income individuals and families will be

eligible for subsidies to help pay for private insurance, unless they have employer or governmental insurance.

– Employers with 50 or more employees will be required to offer affordable insurance coverage or pay a penalty.

– Small employers will be exempt from mandates, but some will be eligible for tax credits if they offer insurance to their workers.

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Overview of Health Reform

• The legislation expands health insurance coverage by:– Covering more people and making it more affordable to many.– Covering preventive services and essential health benefits.

• The legislation provides new funding for:– Health promotion and wellness initiatives.– Expansion of the safety net.– Health professions education and workforce.

• The legislation includes an emphasis on improving quality and efforts to reduce unnecessary health care costs.

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Medicaid (cont’d)• Will I qualify for Medicaid under health reform?

– If you qualify for Medicaid now, you should be able to qualify in 2014 (assuming your income stays about the same).

– Beginning in 2014, the bill expands Medicaid to cover all low-income people under age 65 with incomes up to 133% of the federal poverty level (FPL), based on modified gross income.

– NC will need to decide if they will expand Medicaid to 133% - no longer a federal mandate (Supreme Court Decision)

– Undocumented immigrants will not be eligible for regular Medicaid coverage, regardless of how poor.

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What Plans Will be Available in the HIE?

• What kinds of health insurance plans will be available to purchase in the Health Insurance Exchanges?– All of the plans offered through the Health Insurance Exchanges

(HIEs) will include the essential health benefits.– Insurers will offer bronze, silver, gold, and platinum plans through

the HIE with varying levels of coverage. For example “silver” plans will pay, on average, 70% of the covered health care costs. You will be responsible for paying the remaining 30% of covered health care costs out of pocket.

– In general, the higher the level of plan, the more a person will pay in premiums but the less they will pay in out-of-pocket costs.

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Where is Housing Covered?• It is not….• Housing is only billable in Medicaid for “institutional

level of care”– Nursing Homes– ICF-MR/DD

• That is what has caused some of the concerns nationally and made CMS make changes in their policies of where other services can occur– MFP – DOJ

• The push is settings less than 4 beds and also independent housing arrangements– Scattered sites– Individual leases– Housing and services not tied together.

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CCNC—NC Health/Medical Home• CCNC is the Health Home for NC Medicaid recipients.

– 1.6 million people on Medicaid– 1.2 million assigned to a Health/Medical Home

• 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

Behavioral Health (MH/DD/SA Services)

• Moving from a fee for service model to a managed care, at risk, capitated system

• Is a phased roll out approach– Statewide by July 1, 2012

• Responsible for managing not only day to day behavioral health services but also the implementation of the DOJ settlement

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Proposed Local Management Entity - Managed Care Organizations (LME-MCOs)and their Member Counties on January 1, 2013

Anson

Ashe

Avery

Beaufort

Bertie

Bladen

Brunswick

Burke

Cabarrus

Caldwell

Carteret

Catawba Chatham

CherokeeClay

Cleveland

Columbus

Craven

Currituck

Forsyth

Gates

Graham

Granville Halifax

HarnettHenderson

Hertford

Jackson

Jones

LeeLincoln

Macon

Madison

MontgomeryMoore

Nash

Northampton

Onslow

Pamlico

Pender

Pitt

Polk

Robeson

Rockingham

Rowan

Rutherford

StokesSurry

Swain

Union

Vance

Wake

Warren

Watauga Wilkes

Wilson

Yadkin

Yancey

Smoky Mountain Center Jul 2012

Unless otherwise indicated, the LME name is the county name(s).The lead LME name for the proposed LME-MCO is shown first. Dates shown are the planned Waiver start dates.Reflects plans as of February 9, 2012.

Orange

Transylvania

Person

Western Region Central Region Eastern Region

Cumberland

Scotland

Haywood

New Hanover

Durham

Alleghany

Alamance

Iredell

Johnston

DuplinSampson

Wayne Lenoir

Dare

Hyde

Martin TyrrellWashington

Camden

PerquimansPasquotank

Greene

Alexander

Mitchell

Gaston

Buncombe

CenterPoint Human Services Jan 2013

Caswell

Chowan

Edgecombe

Western Highlands NetworkJan 2012

Davidson

StanlyMecklenburg

McDowell

Durham/ Wake/ Johnston/ Cumberland

Jan 2013

Davie

Coastal Care System(Southeastern Center/ OCBHS)

Jan 2013

Guilford

Randolph

Richmond

Sandhills Center/ GuilfordDec 2012

East Carolina Behavioral Health Apr 2012

Eastpointe/ Southeastern Regional/

Beacon Center Jan 2013

Mecklenburg Jan 2013

Franklin

Hoke

Partners Behavioral Health Management (Pathways/ MH Partners/ Crossroads)

Jan 2013

PBH/ Alamance Caswell Oct 2011/ Five County Jan 2012/

OPC Apr 2012

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Medicaid Personal Care Services

Will there be impact in housing?

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Personal Care Services (PCS) Background Session Law 2012-142, HB 950:

Personal Care Services (PCS) benefits for children and adults

Consolidates services for recipients in private residences and adult care homes, group homes, and combination facilities

Extends Independent Assessment (IA) requirement to recipients in licensed homes

Raises PCS eligibility requirements for recipients in licensed homes to same level as private residences

Eliminates essential errands as an allowable use of PCS services

No other impact for recipients under 21 years due to EPSDT requirements – a federal requirement that each state must follow that requires services be provided to correct or ameliorate conditions and meet conditions of section 1905a of the federal rules.

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New PCS Eligibility(Under Session Law 2012-142, HB 950)

Eligible adult recipients:

Have medical condition, disability, or cognitive impairment, and

Require limited hands-on assistance with three activities of daily living (ADLs),

or hands-on assistance with two ADLs including one at the extensive assistance level

or hands-on assistance with two ADLs including one at full dependence level

Qualifying ADLs are: bathing, dressing, mobility, toileting, and eating

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How is PCS Paid (before Session Law 2012-142, HB 950?)

IN-HOME PCS

15 minute unit - $3.47

Maximum 80 hours per month except for children

Children may exceed 80 hours due to EPSDT

FACILITIES

Daily rateBasic (1-30 beds) - $16.62Basic (31 and above) - $18.21EnhancedEating - $10.26

Toileting - $3.67Eating/Toileting - $13.92Ambulation/Locomotion - $2.62

Special Care Units1-30 beds basic plus - $44.4431 and above basic plus - $48.68

Transportation - $ .57

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How will PCS be paid as a result of SL 2012-142, HB 950?

The PCS State Plan submitted to CMS must be comparable in all areas Payment methodology will be the same across locations (in- home and facilities)

-- 15 minute unit ($3.88)

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Status of Implementation of the Changes (SL 2012-142)

State Plan Amendment submitted to change PCS Makes eligibility, payment methodology and process the same across

settings July 20, 2012—DHHS applied to CMS for a Medicaid State Plan

Amendment (SPA) to implement the required legislative changes

Request for Additional Information (RAI) was received on August 13, 2012. Questions are about

-- limitations of hours and process for determining scope and duration-- Qualifications of providers, supervision of staff, use of nurse aide registry-- Allowable locations of services and type of provider-- Provider Choice

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Status of Implementation of the Changes (SL 2012-142) (continued)

Independent Assessment (IA) Vendor: July 1, 2012—DMA extended Independent Assessment (IA) contract with The

Carolinas Center for Medical Excellence (CCME) – CCME has been conducting the IA for the in-home program– This amendment allowed for the immediate implementation of IA for

recipients in facilities, leveraging existing cost and resources in place for the in-home program

A Request for Proposal (RFP) was posted August 22, 2012 for an IA vendor who will conduct both the in-home and facility PCS– Closing September 25, 2012– Effective date of new contract:

• January 1, 2013 for a planned transition period with current vendor

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Results of Assessments 8/30/2012

144298ACH Bed in NF

Count

Assessments

Completed

SettingPCSNon-

QualifyingPercent

Count

PCSNon-

QualifyingPercent49% 154 52%

1,2402,326Adult Care Home

53% 1,086 47%

84246Family Care Home

34% 162 66%

1688SLF 5600a 18% 72 82%

65218SLF 5600c 30% 153 70%

566715Special Care 79% 149 21%

2,1153,891*GRAND TOTAL 54% 1,776 46%

* Entered into databaseNote. Results reflect approximately 66 percent of assessments completed to date; medical attestation forms have not yet been submitted for the additional 34 percent of completed assessments. These assessments do not represent a valid sample of residents in the facilities. 20

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Are there 17 or more beds in the institution?

Is the current need for institutionalization of

50% or more of residents (using

licensed beds) a direct result of a mental

health/substance abuse illness being the reason

for the placement? Is the overall character of the facility is primarily

for the care and treatment of individuals

with MH/SA?

YES YES

Define the institution – which means what facilities are being examined

The institution is an IMD

NO

The institution is not an IMD

NO

Residential FacilitiesPhase II IMD Process

Determining if a Residential Facility is an IMD

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DHHS Policy Response to DOJ Findings Letter

Will there be impact on housing?

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Agreement Components

In-reach

Diversion

Transition planning

Housing slots with rental assistance and transition supports

ACTT fidelity

Supported Employment

Quality Assurance and Performance Improvement

Independent Reviewer23

Transition Planning

Establish teams coordinated by LME-MCO and headed by Transition Coordinator

Adult Care Homes and State Hospitals with priority on ACH IMDs

DHHS trains transition team based on MFP process and protocols

Establish interest list and tracking mechanism

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Diversion from Adult Care Homes

MUST – Medicaid Uniform Screening Tool

Use of MUST by January 2013 to identify individuals with MH needs seeking admission to ACH

If identified, referred to services

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Supported Housing Slots

Package of rental subsidy, one-time transition supports, community services

Total of 3,000; 100-300 in first year

First come first served and based on geographic housing availability and individual preference

Interest list up to twice the slots of current and subsequent year

Build upon current infrastructure for rental assistance associated with targeted/key housing program

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ACTT Fidelity Fidelity assessment is important for implementation of evidence-

based practices (EBPs), including assertive community treatment (ACT).

Assertive Community Treatment Team (ACTT)

By July 2013 all teams must meet fidelity and will have at least 33 teams serving 3,225 individuals.

By July 2019 50 teams serving 5,000 individuals

Determine which fidelity: DACT (Dartmouth Assertive Community Treatment) or TMACT (Tools for Measurement of ACT)

Training

Identify who will do fidelity assessment

Service definition changes and rate revision27

Supported Employment

Evidence based model – Dartmouth Fidelity Scale

100 individuals by July 2013 building to 2,500 individuals by July 2019.

Involves both SE and Long-Term Vocational Supports

Need to determine what model

Service definition and rate setting

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Quality Assurance and Performance Improvement Tracking length of stay, readmissions, community tenure Personal Outcomes including:

-- Incidents of harm-- Repeat admissions-- Use of crisis beds and community hospital admissions-- Repeat ED visits-- Time spent in congregate day programming-- Number employed, attending school, maintenance of living arrangement, engaged in community life

In-reach and discharge Quality of Life Surveys External Quality Review (EQRO)

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Independent reviewer

Conduct initial baseline evaluation

Evaluate status of compliance

Produce annual reports

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QUESTIONS?

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