Medicaid in North Carolina is now offering new services to people with Medicaid who have an intellectual and/or developmental disability (I/DD), including autism, as well as those with mental health issues and substance use disorders. . In order to receive these services you must be enrolled in a Tailored Plan (Alliance, Vaya, Partners or Trillium). These services are not available in Standard Plans. These 1915i services are starting to replace B3 services. Unlike B3, the 1915i services are an entitlement. This means that the program does not run out of funds to help people and does not keep waiting lists (like the waiver). The same set of 1915i services will be offered across the state, unlike B3 services which varied from place to place.
What kinds of services are part of 1915i?
These 1915i services include:
- Community Living and Support (CLS): CLS includes help for a person on the spectrum that allows them to live at home (whatever type of home that might be) and participate in community life.
- Community Transition: these are services and supports that help someone transition from one setting to another, often from a more institutional setting to one in the community.
- Respite: this service gives caregivers a break by supporting the person with autism in the main caregiver’s absence
- Supported Employment: these are services and support that help someone prepare for work, find employment, and get and keep a job.
- Plus, other services to support those with a primary diagnosis of mental illness or substance use disorders including things like Intensive Recovery Support.
How do I get 1915i Services?
You or your family member with I/DD must be eligible for Medicaid and determined to need these types of services to get them. Medicaid recently changed the eligibility to allow individuals and families up to 138% of the federal poverty level to qualify for Medicaid, so if you did not qualify before December 1, 2023, you might qualify now.
If you or your family member is an adult (19 or older) with an I/DD including autism, and you live in a household with others, you may be able to apply for Medicaid as a “family of one.” For Medicaid, an adult’s “family” is their spouse and their children under the age of 19. So, an adult with autism, who is not married and has no children of their own living with them, would likely be considered a family of one, even if they are living with their own parents and/or other family members. Medicaid eligibility rules differ from IRS rules about households: “for Medicaid, household size may differ for family members even when they are in the same tax filing household. Thus, it is possible that for Medicaid, a family of three filing its taxes together may have two members with a household size of three and the third member of the family may be a household of one.
- How to apply for Medicaid: Contact Medicaid or your local Department of Social Services office to get information on Medicaid eligibility and how to apply.
Your local Department of Social Services will collect the information you provide about your, income, health expenses, etc., and determine if you qualify for Medicaid health care.
- How to get 1915i once you have Medicaid:
You have to have a documented diagnosis of Autism Spectrum Disorder and/or another I/DD to be eligible for 1915i I/DD services. If you do not have a diagnosis that was made by a medical doctor or other licensed health professional (like a psychologist, licensed clinical social worker, or other licensed professional) you will need to get a diagnosis. Assessments done through the school system will not be enough for you or the person on the spectrum to qualify for services under Medicaid.
- Contact your LME MCO to ask about diagnostic assessment options under your Medicaid plan.
- Contact one of our Autism Resource Specialists for more info about resources in your area and accessing services in NC.
- Use the links in the Resources Section at the end to get more information on 1915i and autism.
If you have Medicaid and have an autism and/or IDD diagnosis, contact your Tailored Care Manager or your Care Coordinator at the Local Management Entity Managed Care Organization (LME MCO) and ask to be assessed for 1915i services. The care manager or LME care coordinator will use a standardized assessment tool to determine your eligibility for 1915i services and supports. This is supposed to be done in person. The North Carolina Department of Health and Human Services and/or its review contractor Carelon will review the assessment and if you or your family member is eligible based on the assessment, your Care Manager or Care Coordinator will coordinate with you and potential providers to develop an Individual Support Plan (ISP)or Person-Centered Plan (PCP) for those services.
You do not need to meet the same criteria as for the Innovations waiver (a need for institutional level of care) so if you or your family member does not meet Innovations waiver criteria, consider getting assessed for 1915i services eligibility. You can also use 1915i services and remain on the waiting list for an Innovations waiver slot. These 1915i services will be available through your LME MCO, through Medicaid Direct for those in pre-paid health insurance plans, and through the Specialized Foster Care Plan (when launched).
B3 services are being replaced with 1915i services
If you have Medicaid and are getting B3 services like respite, supported employment, etc. those services will transition to other Medicaid services, and services in 1915i. Over the next few months, people getting B3 services will be assessed for other services and gradually transition to those supports instead of B3.
Can I stay on the Innovations waiver/Registry of Unmet Needs if I am getting 1915i services?
Yes. If you are already on the waitlist or are eligible for an Innovations waiver slot (meet institutional level of care needs or otherwise qualify) you can stay on the wait list or register for the waitlist if you have not already. 1915i services have limited hours that may not cover all the services and supports you need now or over your lifetime: registering or remaining on the waitlist is an important step to ensure you have the supports you need in the future.
Can I get 1515i services if I already have an Innovations waiver?
No. If a person has an Innovations waiver or a Traumatic Brain Injury waiver, they are not getting assessed for 1915i and would not be receiving 1915i services on top pf Innovations services/TBI services. Innovations and TBI waiver are intended to be an all-inclusive set of IDD services. While we understand that it may not include every single thing a person needs for community living, it’s not possible to combine Innovations or the TBI waiver with the community-based supports found in 1915i services. It’s an either/or: either you have a waiver slot, or you are Medicaid eligible and eligible (or receiving) 1915i services.
Your 1915i ISP or PCP
If found eligible for 1915i services, the LME MCO (Care Coordinator) or Tailored Care Manager is responsible for updating or creating the Care Plan/Individual Support Plan (ISP) to include the individual’s 15915i services and supports, including the type, amount, and duration of services. They will also coordinate with providers of that service.
You should participate in the development of the plan, and it should take into account your wishes and the supports you feel that you need. You should be informed of the range of services and providers available in your community.
These updated Care Plans/ISPs will be used by the LME MCO to authorize needed 1915i services. Please note that NC DHHS “believes that individuals who need 1915(i) services will benefit from having a single Care Plan or ISP that documents their whole person needs, including, but not limited to, their need for 1915(i) services. Additionally, because 1915(i) services are Home and Community-Based Services (HCBS), they are subject to federal conflict-free rules, meaning that one provider organization cannot both deliver 1915(i) services and conduct the 1915(i) independent assessment and Care Plan/ISP development for the same individual.” This means that you cannot receive Tailored Care Management and 1915i (or Innovations) services from the same provider at the same time.
Some people may also have a Person-Centered Plan (PCP) in addition to their Care Plan/ISP because they are receiving mental health or substance use services. In most cases, however, a PCP is not required for 1915i services for people with I/DD. For those with both types of plans, information should be updated across the plans for consistency. Your provider will work with you on developing short-range goals for these plans as well.
Resources:
- Contact Medicaid or your local Department of Social Services office for information on Medicaid eligibility.
- Contact your Local Management Entity Managed Care Organization (LME/MCO) for information on local, state, and federal-funded I/DD services you may be eligible for including 1915(i) services.
- Ask your Tailored Care Management Provider/Care Manager to be assessed for 1915(i) services eligibility. If you do not have a care manager, contact your LME MCO and ask for your Care Coordinator to assess you or your family member for 1915i services, and if eligible, to develop an ISP.
- Review 1915i Services Fact Sheet for Providers
- Learn more about the Autism Journey, including getting a diagnosis.
- Learn more about getting a diagnosis as an adult.
- Clinical coverage policies for all Medicaid Services, including 1915i.
- Center on Budget and Policy Priorities article on How does Medicaid determine Household size?
ASNC continues to advocate for increased access to services for people with autism. We are interested in what you have to say about 1915(i) services. Please send any comments or questions on this or other public policy issues to Jennifer Mahan, ASNC Director of Public Policy at jmahan@autismsociety-nc.org.