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The Autism Society of North Carolina is working on updating its 1915 b/c managed care waiver information on our website. Below is an article from The Spectrum ASNC’s newsletter about managed care waivers in North Carolina. Please feel free to post your questions and comments below.

Over the next two years, managed care waivers, also called 1915 (b)/(c) combination waivers, will fundamentally change the way all services for intellectual and developmental disabilities, mental health, and addictive disease/substance abuse (I/DD, MH, SA) are managed and delivered in North Carolina. If you get any state or federally funded services for Autism Spectrum Disorders, including those funded under CAP-MR/DD, Medicaid, state funds (IPRS dollars), and other funding, this will impact you.

Managed care waivers are a BIG change. Under managed care, the Local Management Entity (or LME or sometimes still called the Area Program or Mental Health Center) will get a per-member per-month fee to serve people with I/DD, MH and SA needs in their coverage area. Right now, NC has a fee for service system: the person gets the service and the provider bills the LME or Medicaid for those service hours.

LMEs will manage all public resources to serve MH/DD/SA including Medicaid, Health Choice, state funds/IPRS, federal block grants, and others. This has the potential to impact all publicly funded supports, services, and beds in their region, including state facilities like MR Centers and hospitals, Intermediate Care Facilities for people with I/DD (ICFMR), Community Alternatives Programs for I/DD (CAP MR/DD) services, residential programs, crisis services, developmental therapies, respite, etc. It includes people who are now served, who are on waiting lists, or who could be served in the future.

Managed care waivers save money by promoting “wellness” to avoid future costs and expensive care like hospitals. This is based on a medical model of care that has been shown to work well for people with mental illness and addictive disease. It may work less well for people on the autism spectrum and with other developmental disabilities who do not “recover,” who have lifelong conditions and need habilitative services that build and maintain skills for maximum independence. ASNC hopes it means that people get what they need to live their lives, and savings are focused on providing consistent services and supports, early intervention, and eliminating waiting lists.

It’s moving FAST. Two bills passed the legislature this past session that expand managed care from one region, Piedmont Behavioral Health (PBH), to every LME across the entire state in two years. House Bill 916 expands waivers statewide and Senate Bill 316 allows PBH to expand their waiver to more counties. [Note: Western Highlands LME intends to start the new waiver January 1 of 2012 and Eastern Carolina Behavioral Health LME plans to start April 1 of 2012. News and updates on 1915 b/c waivers from the state Division of MHDDSAS can be found here.]

H 916 does some good. The “aggregate funding” in the bill allows the LME under the waiver to take unused funds and use them to serve more people and/or provide more services and supports to people being served. There is continuity of care language that shows concern for making sure people who are getting services continue to get what they need, though the bill makes no guarantees. There is intent to use 15% of savings in future years to serve more people with I/DD, though the current General Assembly cannot legally obligate a future General Assembly to do so. There is a request to study the feasibility of an “i” option under Medicaid to provide supports to people with I/DD who do not qualify for an ICFMR level of care, but it stops short of committing to make it happen. ASNC will continue to advocate to make these options reality.

H 916 eliminates Targeted Case Management for people with I/DD. House Bill 916 models all future waivers on PBH, which has the LME managing service funds/utilization management (i.e. cost controls), eligibility, assessment, development of person centered plans, and care coordination. H 916 allows an LME waiver site to contract with an outside agency for “treatment plan development” and for the “community guide” service which ASNC believes will allow for some independent development of person centered plans and offers assistance to consumers and families. Care Coordination and Community Guide which is offered under the waiver is different than Targeted Case Management. In addition, the LME controls which providers it contracts with, and for what services, in its closed network.

H 916 does not fix guardianship problems under the waiver. Due to a court decision that says that the waiver LME cannot be an individual’s guardian, its unclear if the waiver LME can contract with an outside organization to provide guardianship services. Unless this is fixed, already over-burdened local Departments of Social Services would need to assume corporate guardianship of individuals. Disability advocates are pushing for a fix to this situation. (This does not affect people who have a friend or relative who is assigned guardianship.)

ASNC urges you to pay close attention to your local communities’ waiver plan development. Every LME has customer relations staff and should be soliciting input from the public as they make these changes. Many things about the impact of waivers are unknown. The Autism Society of North Carolina will continue to provide you with information on the new waivers as we learn more, will work at the state and local level to monitor implementation, and will recommend solutions to any problems that arise.

Please contact Jennifer Mahan, Director of Government Relations, with questions or concerns. She can be reached at 919-865-5068, 1-800-442-2762, ext. 1116 or jmahan@autismsociety-nc.org.

Tags: 1915 waiver, Autism spectrum, case management, Developmental disability, IPRS, LME, managed care, medicaid, public policy