North Carolina Department of Health and Human Services Division of Medical Assistance BUILDING A PERSON-CENTERED SYSTEM OF CARE USING THE TOOLS OF MANAGED CARE, INDIVIDUALIZED ASSESSMENT AND ACUITY BASED BUDGETING SEPTEMBER 14, 2012 Kelly Crosbie, North Carolina Brenda Jackson and Mary Sowers, Mercer September 13, 2012 0 MERCER September 20, 2012
Session Overview • Identifying needs and allocating resources based on needs in a managed care environment and role of Person-Centered Planning • Medicaid Authorities – Options and considerations • The North Carolina Experience – Origins and experiences from a State perspective 1 MERCER September 20, 2012
Multi-faceted Approach to Program Design • Successful program design includes multiple dimensions: – Programmatic – Determination and clear articulation of program goals and objectives (short and long term), meaningful stakeholder (initial and ongoing) engagement, desired operational features and Medicaid authorities that can support them, key partners for implementation and operation, identification of needed tools for success – Financial – Analysis of available resources, initial and ongoing payment design, identification of operational cost components, system-wide analysis (i.e., do the interventions in this program impact other aspects of the service system) – Functional and Clinical Supports – How to improve care, reduce costs, enhance person-centered planning and establish a modern service system that will enable supports for community living, but also foster better health and wellness • And, quality, measurement and state oversight strategies considered through every step… 2 MERCER September 20, 2012
Building the frame – Authority Development • There are more options in Medicaid today than ever before • Careful analysis of each authority is necessary to determine which authority is most advantageous and is most aligned with the State’s short - and long-term goals • For North Carolina’s program design, 1915(b)/(c) Concurrent Waiver authority provided the necessary structure to meet their goal of designing a system that is capable of managing public resources available for mental health, intellectual and other developmental disabilities and substance abuse services 3 MERCER September 20, 2012
The 1915(b) Side of the Frame • Section 1915(b) waivers allow states to: – 1915(b)(1) – mandate managed care enrollment – 1915(b)(3) – use cost savings to provide additional services – 1915(b)(4) – limit number of providers for services – Waive comparability (offer services to a subset of Medicaid eligible individuals) – Waive statewideness (offer services to individuals on a less than statewide basis) – Have multiple programs within a single 1915(b) authority – This gives states the opportunity to utilize a managed care service delivery system (which can take many forms!) • States can: – Elect to use managed care entities to coordinate services, even in a fee-for-service (FFS) environment – Elect to prepay and capitate for services, and share risk with managed care plans for the delivery of services – Include a differing array of services in managed care – full panoply of services or a smaller array – Mandate enrollment in managed care or allow individuals to voluntarily enroll 4 MERCER September 20, 2012
The 1915(c) Side of the Frame • Section 1915(c) waivers allow states to: – Apply institutional income and resource eligibility rules to medically needy individuals – Offer additional supports and services to individuals to live in their homes and communities – Waive comparability (offer services to a subset of Medicaid eligible individuals – Waive statewideness (offer services to individuals on a less than statewide basis) 5 MERCER September 20, 2012
Together, the 1915(b)/(c) Concurrent Waiver • Enables the provision of person-centered HCBS in a managed care environment, enables the use of additional creative services through the use of 1915(b)(3) authority or services provided by managed care plans as cost effective alternatives • The waiver authorities (and related State agreements with partners) can enable person-centered planning and assessment, individualized resource allocation based on acuity and maximum individual choice and control over services 6 MERCER September 20, 2012
1915(b)/(c) Concurrent Authority – Additional Considerations • Each Medicaid authority has its benefits and challenges – and the 1915(b)/(c) concurrent waiver is no exception – Both 1915(b) and 1915(c) requirements continue to apply – so States must consider strategies to align practices to meet both requirements – around issues such as quality, cost effectiveness/cost neutrality and others – However to the extent that dual eligible individuals are in the two waivers, states may apply for concurrent 5 year waivers 7 MERCER September 20, 2012
Managed Community Based Services and Supports Carefully constructed managed care and HCBS authorities can serve as a foundation for a strong service delivery system when coupled with strong state expectations (through contracts and oversight) and strong quality measurement strategies Managed HCBS in NC 1915(b) authority waives freedom of choice and permits HCBS services for individuals from savings 1915(c) authority authorizes HCBS services and institutional eligibility for the DD population Person Centered Integration Individual Control Quality 8 MERCER September 20, 2012
Acuity-Based Budgeting • HCBS service approval not driven by traditional concept of medical necessity (e.g., respite and community attendant based care) • There is still a need to have an equitable distribution of resources • Through strong assessment processes an individual can be given a budget based on their acuity and individual resource accessibility • Through person-centered planning, the participant then has a major role in self-determination of their plan of care services within that budget • Individuals continue to be afforded appeal rights to appeal service authorization denials for services requested • Appendix C- 4 can be used to outline the State’s structure for structuring individual budgets • Now – how it works on the ground… 9 MERCER September 20, 2012
north carolina north carolina NC Department of Health and Human Services medicaid medicaid North Carolina Innovations (c) Waiver & Innovations Plus Kelly Crosbie, LCSW Chief, Behavioral Health Policy Section 10 MERCER September 20, 2012
north carolina north carolina medicaid medicaid HCBS Waivers in North Carolina • CAP-Children (1992) • CAP-Disabled Adults (1982) • CAP MR/DD (now CAP-IDD) — current since 2008 • Innovations (IDD) Waiver (2005 pilot) • Lots of interest around TBI Waiver DMA 11 MERCER September 20, 2012
north carolina north carolina medicaid medicaid Person-Center Planning in North Carolina • Person Centered Plan: Required for any individual receiving community-based mental health, substance abuse, or intellectual/developmental disability services (MH/SA/IDD) • Providers are required to have training in PC Thinking & Planning • “Bumps”— paperwork hurdle or treatment/support philosophy? • Test-run of the SIS — mixed results • Targeted Case Management — what is the goal of the service? – 4 CMS functions? – Advocacy? DMA 12 MERCER September 20, 2012
north carolina north carolina medicaid medicaid NC Waivers & Legislative Actions • 2005 – Pilot 1915 b/c waiver through PBH LME (Local Management Entity) – 5 counties – In 2009 began to explore resource allocation for (c) waiver - Cost overruns - Concerns of “medical necessity” model for determining services - Only part of the state to have MCO care coordination INSTEAD of targeted case management • 2009 SB 897 • RFA Process, the State can select two new demonstration sites; • Complete a Legislative Report to evaluate the impact on I/DD consumers ICFs-MR DMA 13 MERCER September 20, 2012
north carolina north carolina medicaid medicaid NC Waivers & Legislative Actions • 2011 House Bill 916 • PBH allowed to expand • Detailed instructions for statewide b/c expansion by July 2013 • Replicate the “PBH Model” • Protect rates for ICFs-MR & state developmental centers • Eliminate ‘targeted case management’ and implement ‘care coordination’ by MCO • Develop a “resource allocation methodology” for recipients on the (c) waiver —”based on need” • Institute Community Guide (service) • Explore (i) option for IDD services • Reinvest savings into new HCBS waiver slots End Result: 11 Prepaid Inpatient Health Plans (PIHPs) or LME-MCOs DMA 14 MERCER September 20, 2012
Recommend
More recommend
