Medicaid Waiver (CAP IDD) Changes Take Effect Soon – What you need to know

Editor’s Note – The following update was compiled and vetted by Autism Society of North Carolina Senior Director of Quality and Programs Kerri Erb and Director of Governmental Relations Jennifer Mahan. Both these ASNC staff have been following changes to Medicaid Waiver services for quite some time.

Last year, the State of North Carolina submitted applications to renew its Community Alternatives Program (CAP) for people with intellectual and developmental disabilities (IDD), known as the CAP IDD or CAP MRDD waiver to the Federal government. This waiver program allows people who are eligible to receive Medicaid services through an intermediate care facility (ICF MR) to instead utilize those services in home and community settings. This community-based waiver has to be re-approved every 3-5 years.

North Carolina is in the middle of transitioning Medicaid services for people with Intellectual and Developmental Disabilities to a managed care model under another waiver called a 1915 b/c waiver (which for people with IDD is called “Innovations”). Given this transition to managed care, North Carolina officials asked for the current CAP IDD community based waiver to be extended several times. The state was hoping that it could transition to managed care Innovations at the same time so that those on CAP would not have to change services from their current CAP program, to a new CAP waiver program and then to Innovations.

North Carolina’s final extension on its current CAP IDD waiver has ended and the new waiver has been approved to start today, October 1, 2012. The state will transition participants to the new CAP IDD waiver starting this month. People on CAP IDD waivers and their families should not worry; CAP IDD services will continue after October 1. The NC Department of Health and Human Services, who are in change of Medicaid and CAP IDD, are working on the implementation plan for CAP IDD that will give direction to Local Management Entities, case managers, families and providers on what needs to be done and when. This plan may not be finalized until later this week.

As soon as Autism Society of North Carolina has more information about the implementation plan we will share it with families, staff and the public. Below are some of the changes in the new CAP IDD waiver that we have reported previously.

The Biggest Changes in the CAP IDD Waiver:

•  There will be a 129 hour per month limitation on habilitation hours for adults and children.
• “Habilitation” includes Day Supports, Supported Employment, Long Term Vocational Supports and Home and Community Supports.
• The 129 hour limit is inclusive of all these habilitation services; the total number of hours of these services cannot exceed 129 hours.
• The hour limit does not include habilitation hours provided in Residential Supports and/or Home Supports.
• Habilitation hours for children in school will be reduced to 20 hours per week. This includes any week school is in session, even for one day, even if the child is not in school that particular week.
• The 129 hour limit is a monthly limit; it is not a yearly average of habilitation hours.
• Enhanced Personal Care and Enhanced Respite will be restricted to authorizations only for medical reasons (not behavioral).
• Home Supports will no longer be a service under the 2011 CAP I/DD waiver. Personal Care and Home and Community Supports may be used instead of Home Supports. Hours restrictions that apply to rest of waiver apply to those transitioning out of Home Supports.
• Family members can continue to provide Home and Community Supports and Personal Care as they did under Home Supports. Other services under the CAP I/DD Waiver, such as Day Supports and Respite, cannot be provided by family members.

For more information go to The North Carolina Department of Health and Human Services web page for the CAP waiver and see “Overview of New CAP Waiver” near the bottom.

To contact Kerri Erb email kerb@autismsociety-nc.org or call 919 865 5053. To reach Jennifer Mahan email jmahan@autismsociety-nc.org or call 919 865 5068.

What’s in health reform (Affordable Care Act) for people on the autism spectrum?

Editor’s Note – Thanks to Jennifer Mahan, Autism Society of North Carolina Director of Government Relations for the following analysis of last week’s Supreme Court ruling on the Affordable Care Act.

The Supreme Court of the United States recently upheld the Affordable Care Act (ACA) which would expand health care coverage for many people in the United States. It’s a large and complicated law (click here for the Health Care Law website where you can read the complete text of ACA), and the regulations have yet to be written, but it contains a number of items that are of great benefit to people on the autism spectrum including:

• Insurers must cover people regardless of pre-existing conditions, cannot put in place excessive waiting periods for coverage, and cannot selectively refuse to renew coverage.
• Insurers cannot charge different premiums based on health status, gender or occupation.
• Insurance companies have stricter limits on the use of lifetime or annual limits for covering certain health conditions.
• Expands coverage for “behavioral health treatments” and habilitative services, which we believe will include autism therapies like applied behavioral analysis (ABA) and services that help improve and maintain social skills, communication skills, and reduce behavioral problems.
• Allows parents to keep children on their health plans up to age 26.
• Allows states the option to expand coverage of Medicaid to individuals with developmental disabilities (through a variety of home can community based options and flexible coverage options) as well as low-income people, including childless adults, who did not previously qualify for this coverage.
• People who previously could not afford insurance qualify for subsidies to make health care insurance more affordable.
• Small businesses get additional tax credits to offer health care coverage to employees.

For people who have co-existing mental health disorders:

• Requires plans offered through state health exchanges and in the small group market to follow the mental health parity act of 2008, ensuring coverage of mental illnesses and emotional or behavioral disorders.
• Encourages the use of medical homes and improves coordination of primary health care with other behavioral and mental health services.

While the ACA does not cover every person without health care and  does not apply to every kind of insurance, we believe there are many benefits to the law. Some provisions of the law have already gone into effect, and many more will go into effect in January of 2014.

The Autism Society of North Carolina will continue to provide updates about the ACA through this Blog, our monthly email newsletter and on our website.