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Update on Medicaid Transformation: What You Need to Know

The NC Department of Health and Human Services (DHHS) is in the process of implementing Medicaid transformation in North Carolina. In this process, Medicaid recipients will have their health services transitioned from a fee-for-service model to managed care, which allows for physical and behavioral health services to be administered in one plan. Our state’s plan is unique in that it incorporates non-medical elements of health, such as housing, transportation, food security, and other factors, which support healthy living.

Standard plans are scheduled to go live July 1, 2021, while Behavioral Health I/DD Tailored Plans are scheduled to launch July 1, 2022. If you have received a packet about your eligibility for a standard plan, please read this entry carefully.

Based on diagnoses and services, most people with autism will not see changes to the management of their health benefits until the Tailored Plans launch in 2022. Until that second phase, most people with autism will continue to have their health services managed as they are now through NC Medicaid (also known as NC Medicaid Direct) and through their LME-MCO, for behavioral and developmental services, until 2022. We encourage you to read the information below to learn about changes coming this year and next.

 

What is “managed care” and how is NC already managing the care of people receiving Medicaid?

In a managed care model, a health maintenance organization (HMO) such as an insurance company or a provider-led health organization, is paid a per-member, per-month fixed rate to deliver services to people needing health care and related supports. Because these organizations have a limited amount to spend on care, there is a built-in cost incentive to keep people “well” and out of more expensive care.

Several years ago, NC implemented 1915 (b) and 1915 (c) Medicaid waivers to provide services for people with mental health, intellectual and/or developmental disabilities, or addictive disease/substance abuse needs (MH/DD/SAS). This created a managed-care program to deliver home- and community-based and/or long-term care services.

At present, the remainder of Medicaid services for physical health care, including things such as preventative care, doctor visits, emergency care, and long-term care for other special populations, remain a “fee-for-service” program in which providers are paid set fees for specific services directly via the Medicaid program. After the two-year Medicaid transformation program, North Carolina will use a managed-care model to deliver all Medicaid services – physical and behavioral health care as well as services for IDD.

 

What changes are coming to Medicaid?

The new Medicaid managed-care system wants to make sure that the program: 1) integrates physical and behavioral health, 2) addresses the root causes of health conditions, and 3) focuses on healthier outcomes.

During this transformation, Medicaid will integrate physical health care with behavioral health care so that people will, hopefully, be healthier and have an easier time getting services regardless of the type of healthcare needs they have. There will be separate plans to provide this: Standard and Tailored Plans.

  • Standard Plans will be available for those with mild to moderate behavioral health or substance use needs.
  • Tailored Plans will be for those with more complex or lifelong needs (for example, people on the Innovations waiver or the waitlist).
  • People will be enrolled in a Standard or Tailored Plan based on various eligibility factors and their choice.

“Behavioral health” in the Standard Plan will include some services for mental health care and addiction treatment, as well as some autism interventions for children through Research Based Behavioral Health Treatment (also in the Tailored Plan).

Six Standard Plans are currently open for enrollment. To learn more about these plans and eligibility for them, visit this website.

As mentioned above, most people with autism will use Tailored Plans, which begin on July 1, 2022. Tailored Plans are available for those with more intensive needs, including those with autism and intellectual and developmental disabilities (IDD) who are on Innovations waivers, as well as those with serious mental health and substance use disorders. These plans will also integrate physical healthcare and assist with access to housing, residential and employment supports, and other services.

 

How will Medicaid transformation affect IDD and autism services?

  • Intensive behavior treatments for autism, including Applied Behavior Analysis (ABA), that are available under Medicaid State plan services, will be available in both the Standard and Tailored plans.
  • After July 1, 2022, Innovations waiver services (formerly CAP MR/IDD waivers) will only be available in Tailored Plans. People needing intensive IDD services, services such as employment or housing supports, and/or services paid for with funds outside of Medicaid (i.e. IPRS or state-funded services) must be enrolled in a Tailored plan to continue receiving them.
  • Other services such as b3, state-funded Respite, Community Guide, Supported Employment as well as state-funded services such as Personal Assistance, Developmental Therapy, etc., will also only be offered in Tailored Plans.

 

What is the Medicaid Transformation timeline?

Open enrollment for Standard Plans occurs March 15-May 15, 2021. Information on eligibility, enrollment, and plans is available here. Most individuals with autism are likely to require a Tailored Plan (enrollment in 2022) rather than this Standard plan and will not see changes to the management of their health benefits until 2022.

The state is sending enrollment packets this month to families and individuals who are eligible for Standard plans to explain the choices. We understand those who are receiving b3 or other Medicaid services not covered by the Innovations waiver will receive letters indicating they can make a choice in plans. Keep in mind if that if you choose not to remain in NC Medicaid Direct, and are currently receiving services through a LME/MCO such as b3, state funded and or Innovations waiver, those LME-MCO funded IDD services will not be available in the new Standard Plans.

 

What do I need to do if I have Medicaid?  

If Medicaid is your health insurer, you and or your child(ren) and family members will have the option of enrolling in a Standard or Tailored Plan based on eligibility criteria. There are 4 types of situations people may find themselves in. Please read carefully:

1. People who have Medicaid as their health insurer and ARE using Medicaid b3, state funded (IPRS), and/or other Medicaid services (e.g. ABA through Medicaid, Research-Based Behavioral Health Treatment) and are NOT on the Innovations waiver, may get a letter indicating options to enroll in a Standard Plan or remain in NC Medicaid Direct based on eligibility factors.

If this is you, note that b3 and state funded services are NOT available in the Standard Plans. You would need to STAY in Medicaid Direct and with an LME-MCO to continue to be eligible for b3 and state funded services.

2. People who have Medicaid as their health insurer and ARE NOT using Medicaid b3, state funded (IPRS), but ARE using other Medicaid services (in particular, ABA through Medicaid Research-Based Behavioral Health Treatment), and are NOT on the Innovations waiver, may get a letter indicating options to enroll in a Standard Plan or remain in NC Medicaid Direct based on eligibility factors. You may need to check if your provider of preference is in network if you are hoping to change.

If this is you, you may choose to enroll in a Standard Plan; look for one where you can continue any RBBHT, (e.g. ABA through Medicaid Research-Based Behavioral Health Treatment) that you may be currently getting. OR you may choose to stay in Medicaid direct if you think you may need to use b3 or state funded services in addition to RBBHT.

3. People who have Medicaid as their health insurer and ARE NOT using Medicaid b3, state funded (IPRS), and ARE NOT using other Medicaid services, in particular ABA through Medicaid Research-Based Behavioral Health Treatment, and are NOT on the Innovations waiver, may get a letter indicating options to enroll in a Standard Plan or remain in NC Medicaid Direct based on eligibility factors.

If this is you, you can choose to enroll in a Standard plan, but note that b3 and state funded services are NOT available in the Standard Plans. You would need to STAY in Medicaid Direct and with an LME-MCO to get b3 and state funded services, if those are a possibility for you.

4. People who have Medicaid as their health insurer and ARE on the Innovations waiver. Regardless of any other services you may also get besides the waiver (Medicaid b3, state funded/IPRS, other Medicaid services, in particular ABA through Medicaid Research-Based Behavioral Health Treatment). You should NOT be getting a letter enroll in a Standard Plan. If you do, please check with NC Medicaid. If you are on the Innovations waiver you must, for now, remain in NC Medicaid Direct/LME-MCO waiver management. You qualify for the Tailored Plan which begins in 2022.

You will continue to receive your primary health-care services through Medicaid as you do now if you do not enroll in a Standard Plan and are eligible for the Tailored Plan. You should carefully weigh your options and choices as most support services for people with ASD (like b3 respite, IPRS Developmental Therapy, Innovations waiver) are not available in Standard Plans. At this time, most services for people with Autism Spectrum Disorder remain in the Tailored Plan. Again, keep in mind if you choose not to remain in NC Medicaid Direct, and are currently receiving services through a LME/MCO such as b3, state funded and or Innovations waiver, those LME-MCO funded IDD services will not be available in the new Standard Plans.

Individuals who are on the Innovations waiver, CAP/DA, CAP Child or dually enrolled with Medicaid and Medicare will not move into Standard Plans. (Note: There are other exceptions to eligibility criteria.) For children receiving Research Based Behavioral Health Treatment, those services should be available in both Tailored and Standard Plans in addition to regular health services.

It is also important to note that individuals who are on the waitlist for Innovations waiver services will also be automatically enrolled into the Tailored Plan, unless they choose to opt out and into a Standard Plan. As always, it is important for people to get on the Innovations waitlist and to ensure their information is up to date with DSS and LME/MCOs for addresses and service needs. They can maintain their place on the Innovations waiver waitlist if they are eligible to and choose to enroll in a Standard Plan.

If you are eligible for the Standard Plan, more information and contacts for who can help you choose a plan and provider can be found on the Enrollment Broker’s website, found here. If you do choose a Standard Plan, and your needs change for services not available in the Standard Plan, you can seek to move to a Tailored Plan. We will publish more information on this in the future as details are worked out. If you are auto enrolled into a Standard Plan and want to indicate your preference and eligibility for a Tailored Plan, your provider can help you with forms to indicate that need.

 

What behavioral health and IDD services will be available?

Covered by Both Standard Plans and Tailored Plans

  • Inpatient behavioral health services
  • Outpatient behavioral health emergency room services
  • Outpatient behavioral health services provided by direct enrolled providers
  • Partial hospitalization
  • Mobile crisis management
  • Facility-based crisis services for children and adolescents
  • Professional treatment services in facility-based crisis program peer supports
  • Outpatient opioid treatment
  • Ambulatory detoxification
  • Substance abuse comprehensive outpatient treatment program (SACOT)
  • Substance abuse intensive outpatient program (SAIOP) pending legislative change
  • Clinically managed residential withdrawal (social setting detox)
  • Research-based intensive behavioral health treatment
  • Diagnostic assessment
  • EPSDT
  • Non-hospital medical detoxification
  • Medically supervised or ADATC detoxification crisis stabilization

 

Covered Exclusively by Tailored Plans (or LME-MCOs Prior To July 2022)

  • Residential treatment facility services for children and adolescents
  • Child and adolescent day treatment services
  • Intensive in-home services
  • Multi-systemic therapy services
  • Psychiatric residential treatment facilities
  • Assertive community treatment
  • Community support team
  • Psychosocial rehabilitation
  • Substance abuse non-medical community residential treatment
  • Substance abuse medically monitored residential treatment
  • Clinically managed low-intensity residential treatment services
  • Clinically managed population-specific high-intensity residential programs
  • Intermediate care facilities for individuals with intellectual disabilities (ICF/IID)

Waiver Services

  • Innovations waiver services
  • TBI waiver services
  • 1915(b)(3) services

State-Funded BH and I/DD Services

State-Funded TBI Services

 

What are the benefits of Medicaid Transformation?

Both Standard and Tailored (2022) Plans will provide access to care management, which should serve as a central hub to all needs in the Medicaid system. Care management will include “the involvement of a multidisciplinary care team and the development of a written care plan.”

As mentioned at the beginning of this article, one of the goals of transformation is to integrate physical and behavioral health care. Plans must work to address not just health care, but also non-medical drivers of health, such as nutrition and food insecurity, obesity, lack of exercise, smoking, access to transportation, and employment. This holistic approach will benefit all North Carolinians, including the autism community.

This is the largest change to North Carolina’s Medicaid system in 40 years. We applaud the hard work and vision of DHHS to move North Carolina to a healthier population overall. We will continue to inform, advocate, and translate what this means for people with autism in the future. DHHS has a wealth of information online at www.ncdhhs.gov/assistance/medicaid-transformation. You may also contact us at 800-442-2762 (press 2) for additional information. We know this is a complex issue to navigate and we are ready to answer your questions.

 

More information

NC DHHS Medicaid Transformation Website

Standard Plan Enrollment

NC Medicaid Beneficiary Portal

 

 

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