More North Carolina Budget Woes

At the end of the legislative session, state budget writers went from debating a zero to 10 million dollar cut, to taking a 20 million dollar cut out of state funded services for people with developmental disabilities, mental illness and addictive disease. While it is the same cut as last year, it has much greater impact. Local Management Entities (LMEs) are not required to use their fund balances to cover this cut. Most have used their fund balances to prepare for managed care changes and to fund last year’s funding cuts.

In addition, after Legislators finished their session and went home, advocates and LMEs discovered that Legislators had changed the allocation of block grant funds. $8.6 million was to be used for developmental disability services, including $4.3 million which was moved to be used for much needed guardianship services. The remaining 4.3 million was “accidentally” removed and distributed to other areas of the block grant budget.

All of this has resulted in a loss of $24.3 million in funding, mainly for services for people who do not have Medicaid or other health insurance. Reports have begun coming in from regions across the state of cuts in adult vocational services funding and proposed cuts to provider rates. Centerpoint LME issued a statement that they will take $1.7 million in service cuts, including a $633,474 cut to services for people with intellectual and developmental disabilities. Many other LMEs are meeting to discuss what service cuts will result from this loss of funds.

Problems with managed care are taking their toll on funding as well. Centerpoint has asked for $1.53 million in funds from its counties to support the managed care conversion, and Western Highlands, who converted to a managed care model in January of this year, has reportedly been spending $500,000 a month which has resulted in a $3 million dollar deficit in their budget. The Western Highlands CEO was fired and the Board and management  of Western Highlands are now considering 30% rate cuts to providers or other cuts to bring their budget back in line. Many advocates are concerned that drastic rate cuts will force providers to close their doors and cut off access to services or that “efficiencies” to be found mean cutting service hours or whole services.

Every LME and every county will eventually be impacted by the $24.3 million in cuts. The Autism Society of North Carolina asks that you talk with or write to your legislators about service cuts in your region and let us know if you have been directly affected by these cuts. Telling your story is an effective way to get your message across. The legislative oversight Committee on Health and Human Services will meet Tuesday, August 14^th, from 10 AM to 3PM in the Legislative Office Building. We hope to hear of their plans to fix the $4.3 million dollar mistake and what they intend to do to ensure that people do not have services cut.

If you have questions about the budget cuts or other public policy issues, contact Jennifer Mahan, Director of Government Relations for the Autism Society of North Carolina, Jmahan@autismsociety-nc.org or 919-865-5068.

Time is Running Out for Feedback

[Note: this alert was also sent out to the Autism Society of North Carolina's network of subscribers on June 8th, 2012]

 

Time is running out to make your voice heard on the managed care system in North Carolina! The Autism Society of North Carolina, in collaboration with the Arc and other Developmental Disability Advocates, have made recommendations to legislative leadership to improve the managed care system created with House Bill 916 last year. The best way for you to help move these proposals forward is through grassroots contact with lawmakers.

 

The current managed care plan needs changes to meet the needs of people with developmental disabilities, including autism spectrum disorder. The plan needs to:

• Allow for an Independent Care Coordinator so that individuals have someone other than the Managed Care Organization develop the person-centered plan and link to appropriate services.
• Ensure that if an individual has CAP I/DD their slot is portable so they can move within the state without his/her services interrupted simply because of where his/her Medicaid was first established.
• Ensure stakeholders, especially families and individuals, are involved in managed care implementation and oversight.

Legislators have been listening, and we believe they want to fix these issues, but they need to hear from you, their constituents, that you want this to happen!

Tell your legislators that:

 

You support changes to HB 916 (last year’s HB 916 is also known as SL 2011-264: Statewide Expansion of the BC Waiver)

 

Then use the bulleted talking points above in your phone call or email. Briefly tell your story about how autism spectrum disorder is impacting you and your family. Emails will make a difference, but phone calls have even more impact!

 

Please contact:

• NC House Speaker Thom Tillis, Mecklenburg County, Thom.Tillis@ncleg.net or 919-733-3451.
• NC Senate President Phil Berger, Guilford and Rockingham Counties, Phil.Berger@ncleg.net or 919- 733-5708.
• Your Own NC State Legislator,  If you don’t know who represents you, look them up online on the NC General Assembly Web site here.

 

Thank you for taking action on this critical issue. If you have questions about this alert, other policy issues that impact autism, or need help looking up your Legislators, please contact Jennifer Mahan, Director of Government Relations, Autism Society of North Carolina, 919-865-5068 orjmahan@autismsociety-nc.org.

1915 b/c Waivers and Autism: What Does Managed Care Mean to Me or my Child?

The Autism Society of North Carolina is working on updating its 1915 b/c managed care waiver information on our website. Below is an article from The Spectrum ASNC’s newsletter about managed care waivers in North Carolina. Please feel free to post your questions and comments below.

Over the next two years, managed care waivers, also called 1915 (b)/(c) combination waivers, will fundamentally change the way all services for intellectual and developmental disabilities, mental health, and addictive disease/substance abuse (I/DD, MH, SA) are managed and delivered in North Carolina. If you get any state or federally funded services for Autism Spectrum Disorders, including those funded under CAP-MR/DD, Medicaid, state funds (IPRS dollars), and other funding, this will impact you.

Managed care waivers are a BIG change. Under managed care, the Local Management Entity (or LME or sometimes still called the Area Program or Mental Health Center) will get a per-member per-month fee to serve people with I/DD, MH and SA needs in their coverage area. Right now, NC has a fee for service system: the person gets the service and the provider bills the LME or Medicaid for those service hours.

LMEs will manage all public resources to serve MH/DD/SA including Medicaid, Health Choice, state funds/IPRS, federal block grants, and others. This has the potential to impact all publicly funded supports, services, and beds in their region, including state facilities like MR Centers and hospitals, Intermediate Care Facilities for people with I/DD (ICFMR), Community Alternatives Programs for I/DD (CAP MR/DD) services, residential programs, crisis services, developmental therapies, respite, etc. It includes people who are now served, who are on waiting lists, or who could be served in the future.

Managed care waivers save money by promoting “wellness” to avoid future costs and expensive care like hospitals. This is based on a medical model of care that has been shown to work well for people with mental illness and addictive disease. It may work less well for people on the autism spectrum and with other developmental disabilities who do not “recover,” who have lifelong conditions and need habilitative services that build and maintain skills for maximum independence. ASNC hopes it means that people get what they need to live their lives, and savings are focused on providing consistent services and supports, early intervention, and eliminating waiting lists.

It’s moving FAST. Two bills passed the legislature this past session that expand managed care from one region, Piedmont Behavioral Health (PBH), to every LME across the entire state in two years. House Bill 916 expands waivers statewide and Senate Bill 316 allows PBH to expand their waiver to more counties. [Note: Western Highlands LME intends to start the new waiver January 1 of 2012 and Eastern Carolina Behavioral Health LME plans to start April 1 of 2012. News and updates on 1915 b/c waivers from the state Division of MHDDSAS can be found here.]

H 916 does some good. The “aggregate funding” in the bill allows the LME under the waiver to take unused funds and use them to serve more people and/or provide more services and supports to people being served. There is continuity of care language that shows concern for making sure people who are getting services continue to get what they need, though the bill makes no guarantees. There is intent to use 15% of savings in future years to serve more people with I/DD, though the current General Assembly cannot legally obligate a future General Assembly to do so. There is a request to study the feasibility of an “i” option under Medicaid to provide supports to people with I/DD who do not qualify for an ICFMR level of care, but it stops short of committing to make it happen. ASNC will continue to advocate to make these options reality.

H 916 eliminates Targeted Case Management for people with I/DD. House Bill 916 models all future waivers on PBH, which has the LME managing service funds/utilization management (i.e. cost controls), eligibility, assessment, development of person centered plans, and care coordination. H 916 allows an LME waiver site to contract with an outside agency for “treatment plan development” and for the “community guide” service which ASNC believes will allow for some independent development of person centered plans and offers assistance to consumers and families. Care Coordination and Community Guide which is offered under the waiver is different than Targeted Case Management. In addition, the LME controls which providers it contracts with, and for what services, in its closed network.

H 916 does not fix guardianship problems under the waiver. Due to a court decision that says that the waiver LME cannot be an individual’s guardian, its unclear if the waiver LME can contract with an outside organization to provide guardianship services. Unless this is fixed, already over-burdened local Departments of Social Services would need to assume corporate guardianship of individuals. Disability advocates are pushing for a fix to this situation. (This does not affect people who have a friend or relative who is assigned guardianship.)

ASNC urges you to pay close attention to your local communities’ waiver plan development. Every LME has customer relations staff and should be soliciting input from the public as they make these changes. Many things about the impact of waivers are unknown. The Autism Society of North Carolina will continue to provide you with information on the new waivers as we learn more, will work at the state and local level to monitor implementation, and will recommend solutions to any problems that arise.

Please contact Jennifer Mahan, Director of Government Relations, with questions or concerns. She can be reached at 919-865-5068, 1-800-442-2762, ext. 1116 or jmahan@autismsociety-nc.org.

State Budget and Managed Care Waiver Update

NC State Budget

Last week the NC General Assembly passed a budget for the 2011-2013 budget years that was compromise bill negotiated between the NC House and NC Senate, prior to the Senate passing their own budget. In the final version, the General Assembly used the House version of the budget numbers for Health and Human Services (HHS), reducing Senate proposed cuts down to the House levels.  We reported on the House budget in our blog post  and a chart outlining the final cuts in the compromise budget is below. All in all while these cuts in HHS are not good, they could have been much worse. There is a $45 million dollar cut to IPRS state funds for Local Management Entities (LMEs) for services across intellectual and developmental disabilities (I/DD), addiction and mental health services; however the budget directs LMEs to use $25 million of their fund balances, reducing the cut to $20 million. A number of LMEs do not have fund balances, so making up the rest of the $20 million in cuts with existing funds is unlikely. The cut to non-profit funding has been reduced to $5 million dollars. The Medicaid cuts are a combination of savings through increased use of public managed care across the Medicaid system, provider rate cuts, cuts to services like Personal Care, and through additional Federal funding. However, if the NC Department of Health and Human Services is not able to meet their budget, they are authorized to reduce or eliminate optional services including many that could impact people with autism spectrum disorder.  

Education across the board sustained deep cuts.  Early education and development programs like More at 4 and Smart Start took cuts of $16 million and $37 million respectively and will also be required to limit the scope of what they do. Schools were cut by $408 million, with the largest cuts to local school districts of $198 million, non-instructional support $60 million, and instructional support $23 million. The budget adds $62 million in funds for class size reduction in grades 1-3. Universities and Community colleges took cuts in the range of 15%.

Managed Care Waivers

As we mentioned in previous updates, the budget includes proposed savings for implementation of 1915b/c managed care waivers across the intellectual and developmental disability, mental health, and addictive disease system. In addition, two bills have passed the Legislature that expand managed care from one region, Piedmont Behavioral Health (PBH), to every LME across the entire state by July of 2013. Senate Bill 316  allows PBH to expand their waiver to more counties, and has passed both chambers. House Bill 916, which allows for additional waiver expansion to other LMEs was heard in Senate Mental Health and Youth Committee, was passed on the Senate floor and is now headed to the Governor’s desk.

The final version of H 916 does not contain independent case management, but it does allow an LME waiver site to contract for “treatment plan development” and for the “community guide” service which we believe allows some independent development of person centered plans and offers assistance to consumers and families.  The bill contains several other provisions which are a positive step for people with I/DD: aggregate funding, an intent to use future savings to expand services, continuity of care language, and the study of the use of the “I” option for I/DD.

Because the managed care waiver will have a significant impact on everyone with autism who uses any public funding, including CAP MR/DD, Medicaid, IPRS, and any other services they access through the LMEs, we urge you to pay close attention to your local communities waiver plan development.  Every LME has a website and customer relations staff and should be soliciting input from the public as they make these changes. The Autism Society of North Carolina will continue provide you with information on the new waivers, will work at the state and local level to monitor implementation and will recommend solutions to any problems that arise.

The Autism Society of North Carolina has compiled a list of cuts below we feel are relevant to people on the autism spectrum. For a full list of proposed budget cuts, visit the General Assembly web site  and review the articles under the “News and Information” section (left-hand column). The “Money Report” links is a list of cuts, and the “Bill Text” link includes an overview of the funding as well as the “special provisions” stating how funding is to be used and related policy changes. Items in () indicate cuts.

Department	Fiscal Year 2011-2012	Fiscal Year 2012-2013
DHHS Admin
Non-Profit Funding	(5,000,000)	(5,000,000)
CARELINE (handles calls for help, including Medicaid problems)	(380,478)	(380,478)
Div Child Development
Smart Start	(37,600,000)	(37,600,000)
Discontinue transport	(1,001,718)	(1,001,748)
Div of Public Health
Early Intervention	(3,118,046)	(3,118,046)
Div of Medical Assistance
Modify Optional and Mandatory Services (total of several)	(16,508,903)	(22,072,343)
Eliminate inflationary increases	(62,853,778)	(130,874,505)
Adjust provider rates	(46,420,718)	(46,458,260)
Behavioral Health 1915 b/c waiver (includes DD, autism)	(10,537,931)	(52,551,082)
CCNC savings (implementing more medical homes)	(90,000,000)	(90,000,000)
Div of Mental Health, Developmental Disabilities, Substance Abuse
Eliminate 7 advocacy positions (in state facilities)	(158,045)	(158,045)
Eliminate Community Funding (IPRS) for Medicaid recipients, except residential support	(20,000,000)	0
Swap (LME) fund balance w/ state service funds	(25,000,000)	0
Reduce Division management flex funds (emergency fund)	(7,180,807)	(7,180,807)
Education
Public Schools Total Cuts (-$65 mil transferred)	(394,051,894)	(408,543,951)
LEA adjustment (schools return funds to state, make cuts locally)	(124,217,542)	(198,293,574)
Community Colleges Total enrollment growth funded, but tuition increased and all programs cut	(117,475,214)	(117,475,214)
University System Total enrollment funded, but 470 mil flex cut to be determined by UNC	(347,117,332)	(335,057,688)

Managed Care Waivers: A Guide for What You Should Know

There are days in public policy work where it can feel like you are wandering lost, and unlike the woman pictured here there is no map. Then there are the days where you have no shortage of maps, but they all say to go in different directions. One of my jobs at the Autism Society in North Carolina (ASNC) is to try to guide you through confusing public policy issues to help you understand how they could impact you, or your family, or your work. A lot is being written about managed care waivers (1915 b/c waivers) and their impact in people with developmental disabilities, including autism spectrum disorder.   Managed care waivers are going to affect everyone who gets, or could get services and supports for developmental disabilities, through ANY public resource and ASNC thinks you should have good information to guide you and help you guide policymakers to do the right thing.  In addition to the information in this blog, you can find more about waivers on the ASNC website.

Managed care waivers are a BIG change. Managed care waivers, also called 1915 (b)/(c) combination waivers, will fundamentally change the way ALL services for intellectual and developmental disabilities, mental health, and addictive disease/substance abuse (I/DD, MH, SA) are managed and delivered in North Carolina. Under managed care, the Local Management Entity (or LME or sometimes still called the Area Program or Mental Health Center) will get a per member per month fee to serve people with I/DD, MH and SA needs in their coverage area.

LMEs will manage all public resources to serve MH/DD/SA including Medicaid, Health Choice, state funds/IPRS, federal block grants and others. This has the potential to impact all publicly funded supports, services, and beds in their region, including state facilities like MR Centers and hospitals, Intermediate Care Facilities for people with I/DD (ICFMR), Community Alternatives Programs for I/DD (CAP MR/DD) services, residential, crisis, developmental therapies, respite, etc.  It includes people who are now served, who are on waiting lists, or could be served in the future.

Managed care waivers save money by promoting “wellness” to avoid future costs and expensive care like hospitals. This is based on a medical model of care that works well for people with mental illness and addictive disease.  It may work less well for people on the autism spectrum and with other developmental disabilities who do not “recover,” who have life long conditions and need habilitative services that build and maintain skills for maximum independence.  Saving money for those needing this kind of long term support can mean reducing or eliminating services.  ASNC hopes it means that people get what they need to live their lives, and savings are focused on providing consistent services and supports, early intervention, and eliminating waiting lists.  

It’s moving FAST and it will happen FAST. There are two bills moving through the General Assembly that will expand managed care from one region, Piedmont Behavioral Health (PBH), to every LME across the entire state in two years. House Bill 916, expands waivers statewide and will be heard in House Health and Human Services on Tuesday May 31^st at 10 AM. Senate Bill 316 allows PBH to expand their waiver to more counties. S 316 has passed both chambers and now goes to the Governor. 

H 916 does some good things, but can be stronger. The “aggregate funding” in the bill allows the LME under the waiver to take unused funds and use them to serve more people and/or provide more services and supports to people being served. There is continuity of care language that shows concern for making sure people who are getting services continue to get what they need, though the bill makes no guarantees. There is intent to use 15% of savings in future years to serve more people with I/DD, though the current General Assembly cannot legally obligate a future general Assembly to do so. There is a request to study the feasibility of an “i” option under Medicaid to provide supports to people with I/DD who do not qualify for an ICFMR level of care, but it stops short of committing to make it happen.

H 916 eliminates Targeted Case Management for people with I/DD. ASNC believes that it is a conflict of interest to manage the use of services (i.e. the region’s budget/cost of care) and determine an individual’s needs and plan of care. House Bill 916 models all future waivers on PBH which has the LME doing management of service funds/utilization management (i.e. cost controls), eligibility, assessment, development of person centered plans, and care coordination. In addition the LME controls which providers it contracts with and for what services in its closed network. Care Coordination and Community Guide which is offered under the waiver is not equivalent to Targeted Case Management. Please look at the Arc of NC’s response to DHHS’s statement regarding case management under the waiver.

H 916 does not fix guardianship problems under the waiver.  Due to a court decision that says that the waiver LME cannot be an individual’s guardian, its unclear if the waiver LME can contract with an outside organization to provide guardianship services. Unless this is fixed, already over burdened local Departments of Social Services would need to assume corporate guardianship of individuals. [This does not affect people who have a friend or relative who is assigned guardianship.]

What can you do?

1)      Call or email your own NC State Legislators.

By phone: All legislative offices can be reached through the switchboard at 919-733-4111.
By e-mail: Legislative e-mail addresses follow the pattern of <first name dot last name@ncleg.net> (Example: Speaker Thom Tillis’ address isThom.Tillis@ncleg.net) If you have any question about the spelling of your legislator’s name or whether your legislator’s e-mail address uses a nickname, you can confirm addresses at the General Assembly’s web site. Click on “House” or “Senate” and look for Member Lists.

 2)      Contact the Governor’s office directly to express your concerns about the waivers:
By phone: (919) 733-4240
By fax: (919) 733-2120
By e-mail: governor.office@nc.gov

 3)       Attend the General Assembly Health and Human Service committee meeting on May 31^st at 10 AM, where we expect House Bill 916 will be heard.