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NC Medicaid: Waiver v. Non -Waiver Services – What’s the Difference?

There is a 4.9 year waiting list to receive a spot on the Innovations Waiver. The waiting list is unhelpful when you have a child or adult with severe developmental disabilities who needs Waiver services NOW. What services are available for the disabled who qualify for Waiver services, but have not received a spot on the Innovations Waiver yet?

For children (up to age 20), the alternative to the Innovations Waivers is the Community Alternatives Program for Children (CAP/C) 1915(c) Home and Community-Based Services (HCBS) waiver was approved by the Centers for Medicare & Medicaid Services (CMS). The waiver took effect March 1, 2017.

Here is a breakdown of services offered for the Innovations Waiver versus CAP/C:

Category CAP/C Waiver [1] NC Innovations Waiver [2]
Cost limit under waiver $129,000

(Section 5.7.3)

$135,000

(Attachment F)

Case Management 80 hours (320 units) per calendar year

(Appendix B)

Respite 720 hours/fiscal year

Each day of institutional respite counts as 24 hours towards the annual limit.

(Appendix B)

The cost of respite care for 24 hours cannot exceed the per diem rate for the average community ICF-IID Facility
Pediatric Nurse Aide Type, frequency, tasks and number of hours per day are authorized by the case management entity based on medical necessity.

(Appendix B)

In-Home Aide Type, frequency, tasks and number of hours per day are authorized by the case management entity based on medical necessity.

(Appendix B)

Financial Management Service Consumer-directed initiation fee must be assessed the first month of enrollment and shall not exceed 4 units (1 hour).  Monthly management fees shall be assessed each month and shall not exceed 4 units (1 hour) per month.

(Appendix B)

Financial Support Services are available and provider directed.
Assistive Technology Included in a combined home and vehicle modification budget of $28,000 per beneficiary per the cycle of the CAP, which is renewed every 5 years.

(Appendix B)

Limited to $50,000 (ATES and Home Modifications) over the life of the waiver period, 5 years

(Attachment C)

Community Transition Services To transition CAP beneficiaries from 90-day or more institutional setting;

 

One-time expenses, not to exceed $2,500 over the cycle of the CAP, 5 years.

(Appendix B)

To provide initial set-up expense for adults to facilitate transition from community living;

 

Life of the waiver limit of $5,000 per beneficiary.

(Attachment C)

Home Accessibility and Adaptation/Home Modifications Included in a combined home and vehicle modification budget of $28,000 per beneficiary per the cycle of the CAP, which is renewed every 5 years.

(Appendix B)

Home modifications are limited to expenditures of $50,000 of supports (ATES, Home Modifications) over the duration of the waiver, 5 years.
Goods and Services Not to exceed $800 annually (July-June)

(Appendix B)

Not to exceed $2,000 annually

(Attachment C)

Training, Education, and Consultative Services/Natural Supports Education Limited to $500 per fiscal year (July 1-June30)

(Appendix B)

Reimbursement for class and conferences limited to $1,000 per year

(Attachment C)

Vehicle Modification Included in a combined home and vehicle modification budget of $28,000 per beneficiary per the cycle of the CAP, which is renewed every 5 years.

(Appendix B)

Limited to $20,000 over the life of the waiver

(Attachment C)

Community Living and Support (allowing for a paraprofessional) Subject to limits on sets of services

(Attachment C)

 

For adult beneficiaries who live in a private home[3], no more than 84 hours per week for any combination of community networking, day supports, supported employment, personal care, in-home skill-building and/or Community Living and Supports

(Attachment D)

Community Navigator Provider directed service
Community Networking Payment for attendance at classes and conferences cannot exceed $1,000 per beneficiary per plan year.

(Attachment C)

Crisis Services Crisis Intervention and stabilization Supports may be authorized for periods of up to 14 calendar day increments per event.

 

Out-of-home Crisis services may be authorized in increments of up to 30 calendar days.

(Attachment C)

 

Day Supports (A group, facility-based service that provides assistance to the individual with acquisition, retention or improvement in socialization and daily living skills.)

 

Subject to limits on sets of services

(Attachment C)

 

For adult beneficiaries who live in a private home, no more than 84 hours per week for any combination of community networking, day supports, supported employment, personal care, in-home skill-building and/or Community Living and Supports

(Attachment D)

Residential Supports (for Group Home or Alternative Family Living) Subject to limits on sets of services

(Attachment C)

 

For adult beneficiaries who receive residential supports, no more than 40 hours per week for any combination of community networking, day supports and supported employment services.  For child beneficiaries who receive residential supports, during the school year, no more than 20 hours per week for any combination of community networking, day supports and supported employment services.

(Attachment D)

Supported Employment Services (provide assistance with choosing, acquiring, and maintaining a job for beneficiaries 16 and older) Subject to limits on sets of services

(Attachment C)

 

For adult beneficiaries who live in a private home, no more than 84 hours per week for any combination of community networking, day supports, supported employment, personal care, in-home skill-building and/or Community Living and Supports

(Attachment D)

Supported Living (flexible partnership that enables a person to live in his own home with support from an agency that provides individualized assistance in a home that is under the control and responsibility of the person Subject to limits on sets of services

 

For adult beneficiaries who live in a private home, no more than 84 hours per week for any combination of community networking, day supports, supported employment, personal care, in-home skill-building and/or Community Living and Supports

(Attachment D)

 

Person receiving Supported Living may not also receive Community Living and Supports, Respite Services or Personal Care Services

[1] See NC Division of Medical Assistance, Clinical Coverage Policy No: 3K-1, Amended Date: March 1, 2018.  The CAP/C waiver was renewed by CMS effective March 1, 2017-February 28, 2022.

[2] See NC Division of Medical Assistance, Clinical Coverage Policy No: 8-P, Amended Date: November 1, 2016.

Could NC Hospitals Be the Surprising and Much Needed Advocate for Mentally Ill Medicaid Recipients?

North Carolina has created the perfect storm when it comes to mentally ill…the perfect scenario for disaster.  10…9….8…..7……6…….5……..4………3………..2…………..

From 2001 to 2012, the total population of North Carolina increased from 8,203,734 people to 9,781,022.  Over 1 and a half million more people live here now than twelve years ago.  Which is understandable when you think about all the people relocating here.

The number of NC residents in need of mental health services has increased from 517,447 in 2001 to 613,379 in 2012 (not sure how many are on Medicaid).  However, since 2001, the number of inpatient psychiatric beds has DECREASED by fifty percent (50%), from approximately 1,750 beds to approximately 850 beds.  850 beds!!  Not even enough beds to serve 1/10 of the population in need!!

In the past, it was understandable to decrease the number of psychiatric beds.  NC was doing a fairly decent, not perfect, by any means, but a decent job of providing community-based mental health services to those in need. 

Those days of decent care for mentally ill Medicaid recipients are over.  Instead, we have the perfect storm for utter disaster.

Enter main ingredient of the perfect storm…the managed care organizations (MCOs).  In NC, we moved only behavioral health care to the MCOs.  Basically, if you are on Medicaid and need any type of health care services, besides behavioral health services, you will never come into contact with an MCO.  However, if you suffer from a mental illness, a developmental disability, or a substance abuse problem and rely on Medicaid for insurance, you have encountered the MCOs.

Prior to 2013 (except for the experimental 1st MCO, which was called Piedmont Behavioral Health, but now called Cardinal Innovations), the MCOs did not exist.  Literally, the MCOs have gone “live” this year.  The MCOs are new to being the gatekeepers of mental health services for Medicaid recipients in NC.

Not only do we have these new, inexperienced companies deciding which Medicaid recipients may receive mental health services, but we, in our great wisdom, gave them the monetary incentive to DENY services to recipients and to DENY providers Medicaid contracts, which is the 2nd ingredient for the perfect storm.  Oh yes, we did all that!  The MCOs are prepaid.  So, in theory, the MCOs are taking the burden of risk (i.e., going over budget) off the State and onto themselves.  If the MCOs go over budget, it is on the MCOs to come up with the money.  However, in reality, the MCOs, to save on money and increase profit, are denying medically necessary services and terminating (or not enrolling) quality health care providers.  See my blog “The NC Medicaid Mental Health 10-Ring Circus: How 10 Mini Jurisdictions Will Be the Downfall of Mental Health.”

Enter the 3rd ingredient to the perfect storm…the Department of Health and Human Services (DHHS), Division of Medical Assistance (DMA)’s complete absence of supervision of the MCOs.

The MCOs have full reign and uninhibited authority to deny mental health care services, to terminate Medicaid provider contracts, or to refuse to contract with Medicaid providers with absolutely ZERO repercussions (unless you hire an attorney (not necessarily me) and obtain an injunction) from DMA, from the federal government, from anyone.  See my blog “The MCOs: Judge, Jury, and Executioner.”

[The equation for the perfect storm = the decreased number of psychiatric beds + increase in population + the increase of mentally ill residents + the MCOs + the monetary incentive for MCOs to deny services and not enroll providers + DMA’s complete lack of supervision]

As I am sure you are aware, a week or so ago, Virginia state Senator Creigh Deeds was stabbed multiple times by his son.  Deeds was hospitalized for three days, but his son took his own life after stabbing his father.  According to the media, Deeds’ son, Gus Deeds, suffered from severe mental problems and the day prior to the stabbing, an emergency custody order was sought.  However, a psychiatric bed, reportedly, could not be found.

Sadly, the tragic story of Gus Deeds is too common.  In Modern Healthcare this week, the feature story is called, “No Room for the Mentally Ill.”

The article discusses how the hospitals “are trying to collaborate with other hospitals  to place psychiatric patients in open beds, using separate psychiatric EDs, setting up crisis triage centers, and referring patients to residential treatment centers.” See Modern Healthcare, dated November 18, 2013.

The hospitals may be acting in a self-serving manner.  Most mentally ill patients, who are admitted to the ERs are not paying clients.  The hospitals cannot turn a profit if too many non-paying clients are admitted to the ER.  However, whatever the motivation, I say, thank goodness, and God bless the hospitals’ efforts!

Mentally ill, Medicaid recipients may be the demographic with the LEAST voice of all demographics in existence. 

Sadly, few care about poor people, and even fewer care about poor people suffering with MH/DD/SA. (When I say “care,” I mean will devote time, resources, and energy to them.  I mean hire lobbyists for them, hire attorneys.)

Here, in NC, we are staring into the face of a perfect storm.  If the hospitals can make headway with a bigger voice than those depending on Medicaid with behavioral health issues, God bless the hospitals, whatever the reason for their advocacy.

Because, perhaps, without the hospitals, we could be seeing:

3….2…..1……BOOM!