Category Archives: State Plan
The NC State Plan, Its Importance, and How Can We Keep Up With All the Changes??
I am constantly amazed at the amount of knowledge that I do not know. And how quickly the knowledge I have becomes obsolete due to changes. To quote Lewis Carroll’s “Alice and Wonderland,” “Why, sometimes I’ve believed as many as six impossible things before breakfast.” My other favorite quote series from Lewis Carroll is the following scene:
“But I don’t want to go among mad people,” Alice remarked.
“Oh, you can’t help that,” said the Cat: “we’re all mad here. I’m mad. You’re mad.”
“How do you know I’m mad?” said Alice.
“You must be,” said the Cat, or you wouldn’t have come here.”
So too, must I be mad, I think, at times, for dealing with Medicaid and Medicare law. The statutes and regulations are vast and ever-changing. You can easily miss a policy change that was disseminated by an update posted on the web. But, I am a lawyer…I read a lot. But providers are held accountable as well for every revision and every update.
Just when you think you understand the State Plan, the Department of Health and Human Service (DHHS) asks the Center for Medicare and Medicaid Services (CMS) for an amendment.
In this blog, I am going to discuss 2 issues. (1) What is the State Plan and why is it important; and (2) how can providers stay abreast of the ever-changing Medicare/caid world and policies.
(1) Our State Plan
What is our State Plan in Medicaid? Is it law? Guidance? Does NC have to follow the State Plan? Can NC amend the State Plan?
These are all good questions.
The State Plan is a contract between North Carolina and the federal government describing how NC will administer its State Plan, i.e., Medicaid program. The State Plan describes who can be covered by Medicaid, what services are available, and, basically, assures the federal government that we will abide by certain rules and regulations. NC must follow the State Plan or risk losing federal funding for Medicaid, which would be BAD.
Quite often, the Department of Health and Human Services (DHHS) will issue a State Plan Amendment (SPA) to the Centers for Medicare and Medicaid Services (CMS). DHHS has to post all proposed amendments on its website “10 Day Posting for Submission to CMS.” This internet site should be in your “favorites,” and you should check it regularly.
For example, February 27th, DHHS asked to reduce Medicaid reimbursements methodologies for Chiropractic Services, Podiatry Services and Optometry Services to 97% of the July 1, 2013, rate, effective January 1, 2014 (yes, retroactively).
Just in 2014, there have been approximately 10 SPA requests. So, these SPAs are relatively common.
So, question #2…how can you keep up?
(2) Keeping abreast of all changes
As much as I would love to throw my computer out the window (I am on the 16th floor) and watch it crash, computers and technology can be very helpful. And technology makes it easy for everyone, even busy health care providers, to stay current on changes, amendments, and revisions to Medicaid/care policies and law.
Here is the secret: (shhhhhhhhh!!)
Google Alerts.
If you want to keep current on NCTracks, all you have to do is set a Google alert with the search term “NCTracks,” and you will receive daily email alerts on all internet articles on NCTracks. It is that easy.
So how do you set up a Google Alert? I have drafted a set by step process, otherwise entitled “Google Alerts for Dummies.”
1. Go to Google.
2. At the top of the page you will see the words: “You,” “Search,” “Images,” “Maps,” “Play,” “Youtube,” “News,” “Gmail,” and “More.” Click on “More.”
3. When the box drops, at the very bottom, you will see “even more.” Click on “even more.”
4. Scroll down to specialized search and click on “Alerts.”
5. Type in whatever search term you like, such as “Medicaid,” or “Knicole Emanuel.”
6. Decide how often you want to be alerted and your email address.
You will now be alerted about your topic. See? Easy!!
Now, because of this blog, you have learned two or more impossible things before lunch.
An Ominous Cloud Looms Over NC’s Mental Health System! And Radix Malorum Est Cupiditas!
“There is an ominous cloud over North Carolina’s mental health care system that many fear is limiting access to care and treatment by those who need it the most,” wrote Jason deBruyn in Friday’s Triangle Business Journal article titled, “Mental Health Block.”
(Thanks, Jason, for the nice spread:) )
Two phrases that can never be good when linked together: “an ominous cloud” and “mental health care system.” Upon reading “ominous cloud,” I get this dark (dare I say ominous?), dreary outlook on whatever the “ominous cloud” is over. Then to discover that the “ominous cloud” is over our mental health system here in NC, I get goosebumps and a pit in my stomach (and a bit of disgust at the sheer ineptness of the Department of Health and Human Services (DHHS)).
What is causing that “ominous cloud” over our mental health system? Well, according to Jason, the managed care organizations (MCOs) that were implemented across the state only this past year.
What are these MCOs you talk of?
The MCOs were established to manage the Medicaid mental health, developmentally disabled, and substance abuse services in NC. If you want mental health services or are attempting to get prior authorization on behalf of a Medicaid recipient, then the buck stops with the MCO. See my blog: “NC MCOs: The Judge, Jury and Executioner.” Or “NC MCOs: Accountability Must Be Somewhere!”
Here is a list of the MCOs along with the “correct toll free number” in case you wanted it:
| LME-MCO | CORRECT TOLL FREE NUMBER |
| Alliance Behavioral Health | 1-800-510-9132 |
| Cardinal Innovations Healthcare Solutions | 1-800-939-5911 |
| CenterPoint Human Services | 1-888-581-9988 |
| CoastalCare | 1-855-250-1539 |
| East Carolina Behavioral Health (ECBH) | 1-877-685-2415 |
| EastPointe | 1-800-513-4002 |
| MeckLINK | 1-877-700-3001 |
| Partners Behavioral Health Management | 1-888-235-4673 |
| Sandhills Center | 1-800-256-2452 |
| Smoky Mountain Center | 1-800-849-6127 |
| Western Highlands Network | 1-800-951-3792 |
Going back to the “ominous cloud…”
Jason writes further that “under the state’s new payment system, MCOs have the unbridled authority to terminate providers in an attempt to keep costs down – with little accountability for the process.”
The only word I would change is “little” to “no.” But, then, maybe Jason was referring to the little accountability as arising from advocates such as myself who are fighting for the providers.
Have I not been saying this all along? The MCOs can terminate providers with little (or no) accountability!! To save money!!
And who suffers?? The providers, yes. And the Medicaid recipients!! “Patients aren’t going to know where to go to access services,” Goldston says. “Those patients are going to suffer.”
Why? Why are these MCOs terminating providers and denying services to our most-needy population?? Have they no heart? No conscience?
One word answers all these questions:
Money
Radix malorum est cupiditas, meaning, in Latin, greed is the root of all evil. In the Bible, 1 Timothy 6:10, starts “For the love of money is the root of all kinds of evil…”
“MCOs register as not-for-profit organizations and receive fixed amounts of money from the state, called their “capitation.” Unlike physical health care providers, when Medicaid patients receive mental health services, their providers bill these MCOs instead of the N.C. Department of Health and Human Services. If an MCO doesn’t spend up to its capitation level, it keeps the remainder. And therein lies the problem, say provider advocates,” writes Jason. (emphasis added).
And he is absolutely correct!
What was the MCOs’ response?
“The myth that we are trying to eliminate every provider in our network is not an accurate statement,” says Rob Robinson, chief operating officer for Alliance Behavioral Healthcare, the MCO that covers Wake, Durham, Johnston and Cumberland counties.
Mr. Robinson’s comment, however, is incorrect on, at least, two fronts: (1) the “myth” is not that the MCOs are trying to eliminate every provider; and (2) it is no myth. The MCOs are, without question, terminating as many providers from the networks as possible without the appearance that services will not get rendered. The MCOs need a certain number…just to appear that services are not getting cut.
So what is that magic number?
A client informed me a couple of months ago that Smokey Mountain Center (SMC) told him that SMC wants two providers per service per county. If correct, hundreds and hundreds of providers will be put out of business. And, hello…I thought the current Republican administration was pro small business!
Alliance has chopped its provider network recently.
Just recently, Alliance called for Requests for Proposals (RFPs) from all contracted providers within its catchment area. Kinda like a tryout. When I was in college at NCSU, I was on the cheerleading team. I will never forget being a freshman and learning these routines that I would have to perform in front of a judge’s panel. Literally hundreds of young men and women were all learning the same routine…all to perform for the tryouts. In the middle of learning the routine with hundreds of people, I looked around and realized that only 8 girls and 8 guys would be chosen. Which meant 90% of the people there would not be on the team. I tried to remove the thought from my head.
When the D-Day arrived, there was simply a white piece of paper taped to the gymnasium’s window on the outside for anyone to see. I had to walk up to the piece of paper, shuffle through the small crowd surrounding it, ignore others’ tears and congratulations, and look for my name.
Holding my breath, I searched for “Knicole Carson” (my maiden name). And I did not see it. For a moment, I was crushed. Then I saw “Nicole Carson.” My name was on there, just misspelled.
What does college cheerleading tryouts have to do with NC Medicaid?
Alliance’s RFPs created a provider tryout. Hundreds submitted. Only a few were chosen. Those few chosen were written on a piece of paper for all to see, and providers had to scan the list to see if they were chosen.
For Wake county, Alliance decided to award a 1 year contract for community support team (CST) to only 6 companies. For the entire county of Wake, Alliance has determined that only 6 companies may provide CST to Medicaid recipients (with a 1 year contract). Only 6 names were on the list.
For Durham county, Alliance decided to award a 1 year contract for CST to only 5 companies. For the entire county of Durham, Alliance has determined that only 5 companies may provide CST (with a 1 year contract). Only 5 names were on the list.
Now let’s go back to Mr. Robinson’s comment:
“The myth that we are trying to eliminate every provider in our network is not an accurate statement,” says Rob Robinson, chief operating officer for Alliance Behavioral Healthcare, the MCO that covers Wake, Durham, Johnston and Cumberland counties.
You are right, Mr. Robinson, you aren’t trying to eliminate “every provider.” Just the ones that Alliance, in its subjective discretion, doesn’t want to deal with (I don’t care that I ended the sentence in a preposition).
Oh, and what about our State Plan?
Our State of North Carolina MH/DD/SA Health Plan Renewal, states, in pertinent part, as an answer regarding concerns as to provider choice with MCOs, “network capacity studies and gap analyses were conducted by Cardinal Innovations Healthcare Solutions (CIHS) annually and prior to expansion the coverage area, and by the new PIHPs prior to start-up, as required. Access and provider choice appear to be as good as or better than it was prior to waiver implementation, although there is room for improvement in several areas.” (emphasis added).
Obviously, that was written a while ago and Cardinal, an MCO, was the entity conducting the study (cough, cough…bias…cough). Regardless, we told the federal government that “provider choice appears to be as good or better than it was prior implementation.” Are you kidding me???
How many providers didn’t make Alliance’s cut?
How many providers have MeckLINK terminated? Smokey Mountain?
Jason deBruyn was dead on when he said, “There is an ominous cloud over North Carolina’s mental health care system that many fear is limiting access to care and treatment by those who need it the most.”
Attention Medicaid Providers: Potential SPA Decreases PCS Rates By 60 Cents Per 15 Minutes
The North Carolina State Medicaid Plan (State Plan) is constantly revised. The result of its constant revisions make for an 1800+ page, jumbled mess of plans, rules, amendments, and effective dates that make the State Plan as much fun to read as reading every volume of the Encyclopedia Britannica in Japanese with the aid of a Japanese translation dictionary.
First of all, what the heck is the State Plan? Basically, a State Plan is a contract between a state and the Federal Government describing how that state administers its Medicaid program. It “assures” the federal government that we, here in NC, will follow the State Plan because the federal government has “blessed” our State Plan. Whenever we need to change the State Plan, we file an amendment. In circumstances that call for much greater deviation from the State Plan, we can apply for a Waiver…or an exception.
On or about August 15, 2013, the Department of Health and Human Services (DHHS) issued a Public Notice “providing notice of its intent to amend the Medicaid State Plan for the purpose of defining the reimbursement methodology of Personal Care Services as directed by Section 10.9F of Session Law 2013-306 (House Bill 492). “
Personal Care Services (PCS) are Medicaid-covered, in-home services to recipients “who have a medical condition, disability, or cognitive impairment and demonstrates unmet needs for, at a minimum three of the five qualifying activities of daily living (ADLs) with limited hands-on assistance; two ADLs, one of which requires extensive assistance; or two ADLs, one of which requires assistance at the full dependence level. The five qualifying ADLs are eating, dressing, bathing, toileting, and mobility.” See DHHS Website.
In a letter dated September 30, 2013, and signed by Sec. Aldona Wos, DHHS sent what is called a SPA or a State Plan Amendment to the Centers for Medicare and Medicaid Services (CMS), in part, asking to be allowed to change the PCS unit rate from $3.88 to $3.28.
$3.88 to $3.28…
It may not sound like a huge decrease in pay to you, but a 60 cent drop per unit will be extremely harmful to providers who provide PCS services and, ultimately Medicaid recipients because less providers will be willing to serve the population.
One PCS unit is 15 minutes. There are 4 units in an hour. A 60 cent/unit cut to the rate will result in a $2.40 hourly cut.
Providers who employ staff who provide PCS are not paying staff upwards of $20/hour. Oh, no, most PCS providers make, maybe, $7-9.
Think about it…a small business provider of PCS (Let’s call it ABC Provider) employs 5-10 staff to provide PCS to recipients. ABC Provider has to pay its overhead (lease, office supplies, salaries of execs) plus pay the hourly wages of the PCS staff, and, supposedly, still make a profit…otherwise why even work?
For one hour of PCS, prior to a rate reduction, ABC Provider grosses $15.52/hour. Obviously, a portion of the $15.52 must go to overhead. ABC Provider pays her staff $9.00/hour. So ABC Provider nets $6.52/hour to pay for overhead. After 1000 man-hours, maybe ABC Provider can pays its rent and its utility bill. BTW: In order to reach 1000 man hours, it would take a person to work 41.66 days, 24 hours/day. Or it could take 10 staff working 10 hours/day for 2 weeks…just for the provider to make $6520 to pay bills…we aren’t even talking about profit…
After the rate reduction?
$2.40 has to be recouped somehow. Does the provider’s profit margin shrink or does the employee’s hourly rate decrease? Maybe a little of both.
According to the September 30, 2013, Sec. Wos letter, NC DHHS requested a retroactive date for the PCS rate reduction to July 1, 2013, or, in the alternative, October 1, 2013.
What? Retroactive reduced rates? Would DHHS recoup payments already made?
As of the day of this blog, I have not found out whether CMS approved the SPA sent to CMS September 30, 2013. I looked on CMS’ website. So if anyone reading has information as to whether CMS approved, is approving, denied, or is denying the rate reduction, I, as well as other people, would be much obliged for the information.
