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.

Period.

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.