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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