What is the Difference Between the 1915 b/c Waiver and Technical Guide?

Do you know the difference between the 1915 b/c Waiver and the Technical Guide?

You should!  (If you provide Medicaid mental health or substance abuse services or services to developmentally disabled persons).

What is the 1915 b/c Waiver (the “Waiver”)?

It is a document (a very large document) that all health care providers, recipients and State agencies must adhere to in order for Medicaid recipients to receive the medically necessary services needed.  The consequence of anyone in NC not following the Waiver? The feds can come and recoup Medicaid money…or perform any other allowable remedy/punishment.  Basically, everyone in NC (germane to Medicaid) must follow the Waiver or answer to the federal government.

The Waiver applies to Medicaid recipients suffering mental health issues, developmental disabilities, and substance abuse.

The Centers for Medicare and Medicaid Services (CMS) granted the North Carolina Waiver, which operates under Section 1915 (c) of the Social Security Act. This Waiver operates concurrently with a 1915 (b) Waiver, the North Carolina Mental Health/Developmental Disabilities/ Substance Abuse Services Health Plan (NC MH/DD/SAS Health Plan).

In sum, the Waiver is a document approved by the federal government (CMS). The Waiver applies to Medicaid recipients suffering mental illness, developmental disabilities and substance abuse.  We must adhere to the Waiver…or else.

So what is the Technical Guide?

First, what is it not? If the Waiver is Medicaid “law,” the Technical Guide is not.

When you were in high school, did you ever read Cliffsnotes?  You know, your English teacher assigns “The Great Gatsby,” but you have so many other important things to do in high school other than to read “The Great Gatsby.” So you get the Cliffsnotes.  Easy enough, right?

Until your teacher tests on details in “The Great Gatsby” that were not in the Cliffsnotes…

I am NOT (capital N.O.T.) comparing the Technical Guide to Cliffsnotes.  The Technical Guide is approximately 350 pages.  If Cliffsnotes were 350 pages long, then the actual book would be over 1000 pages.  If the Division of Medical Assistance (DMA) were attempting to draft an abridged version of the Waiver with the Technical Guide, then someone grossly misunderstood the word “abridged.”

DMA prepares the Waiver, and (although I have never been present for the process of its creation) I believe that DMA works extraordinarily hard on the Technical Guide.

Despite, DMA’s hard work, the Technical Guide, generally, is  not identical to the Waiver.

If the Technical Guide were identical to the Waiver, then the Technical Guide and the Waiver would be identical, right?

The Technical Guide is supposed to be a “user-friendly” rendition of the Waiver.  Because, folks, I am here to tell you, the Waiver is NOT “reader-friendly.”

But….beware….if it comes down to a legal argument in a court of law, the Technical Guide is not law…the Waiver is law.  So if you are having your employees read the Technical Guide in lieu of the actual Waiver, you MAY be in violation of the Waiver, even though you meet the Technical Guide criteria.

For example, in the Technical Guide, for authorization of In-Home Intensive Supports, for prior authorization, a Medicaid recipient could use (for prior authorization):

“Until the participant has a Supports Intensity Scale assessment [SIS assessment], the NC SNAP is used and the participant must have a score of at least 4 or 5 in Medical and/or Behavioral.”

According to the Technical Guide, a SNAP score can be used in order to receive authorization for In-Home Intensive Services.

However, the Waiver says nothing about a SNAP score.  According to the Waiver, the ONLY document that can be used for prior authorization for In-Home Intensive Supports is the SIS assessment.


Not the SNAP!

Ambiguity? I think so…

But, when the English teacher tests on the details of “The Great Gatsby” that were not found in the Cliffsnotes, you fail.

Similarly, when you only follow the Technical Guide, you may find yourself (legally) holding the “Cliffsnotes of the Waiver.”

And liable.

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on August 29, 2013, in 1915 b/c Waiver, Behavioral health, CMS, Division of Medical Assistance, DMA Clinical Policies, Health Care Providers and Services, In-Home Intensive Supports, Medicaid, Medicaid Recipients, Medicaid Services, Mental Health, Mental Health Problems, Mental Illness, NC DHHS, North Carolina, SIS Assessment and tagged , , , , , , , , , , , , , , , , , , , . Bookmark the permalink. 3 Comments.

  1. I so enjoy reading your postings. One question, I have does the waiver state that in order to have In Home Intense that a fading plan is required. On one part of the technical guide it states “if required” but in the section with the service definition it states must have a fading plan. Everyone I ask does not seem to know the answer and for the most involved individuals who qualify for In Home Intensive there is no fading plan except to be honest, their death. I am the Guardian of a very medically fragile young lady who was a shaken baby at 7 weeks, she is now 22 and only weighs about 50 pounds. I have had to fight every year for appropriate service. Thanks for any assistance you can give me. Jane Lindsey 104 Muirfield Court Hendersonville, NC28791

  2. I too enjoy reading your blog. I find it interesting that you think a lot like me. I have a 31 year old daughter that has a rare chromosomal abnormality and is once again faced with not receiving the services she needs. We have appealed denials in the past (from 2005 thru 2009) and won each one of them. We are now being denied what has been proven medical necessity numerous time. Here are questions I have sent to Deb Goda but have yet to receive an answer. Hopefully you can shed some light.
    1. Is a fading plan required? (On page 9 of the Clinical Coverage Policy 8P it states “if indicated” yet on Page 55 it states “The ISP includes an assessment and a fading plan or plan for obtaining assistive technology to reduce the amount of intensive support needed by the beneficiary). Some consumers have extensive needs and a fading plan is not feasible.
    2. Is the service intended to address acute needs only? Consumers are on the innovations waiver because their needs are long term and require ICF care. A person does not move into an ICF and out in 90 days because they no longer meet ICF criteria. Please help me understand this.
    3. Can the service be approved for more than 90 days at a time if the need is present? This is a costly administrative duty that is unnecessary if it is justified that the need is going to last longer than 90 days.
    4. What are the options when a consumer has a need that is above the “Sets of Service Limits” yet their needs can be meet in their private residence and their base budget services and non-base budget services are at or below the $135,000, which is much less than the cost of institutional care, when the SIS has not been implemented.
    Any light you can shed will be greatly appreciated.

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