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.

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)

Senate Budget Released: More Cuts to Autism!

On May 24, the North Carolina Senate released its version of the state budget, which cuts an additional 3% from Health and Human Services programs, including $30 million in cuts to state funded services (IPRS), $51 million more in cuts to Medicaid optional services for adults, $10 million in cuts to non-profits, and $25 million more in cuts to Medicaid provider rates, bringing the total to $71.4 million.

The budget includes proposed cuts to 21 of the 26 “optional” Medicaid services for qualifying adults. Potential “optional services” that may be impacted include funds for Intermediate Care Facilities for people with intellectual and developmental disabilities (ICF-MRs), dental care, optical care, physical therapy, occupational therapy, speech therapy, personal care services, case management, and medication. The NC Department of Health and Human Services would be required to reduce the amount of service, lower payment rates, or eliminate a service altogether to make up for the loss of $51 million in funding. When combined with Medicaid matching funds from the federal government, this means a loss of $200 million dollars in Medicaid funding for “optional” but completely necessary services. Many of these programs have already been cut recently; in the case of Medicaid provider rates, this would bring the total rate cuts to 11-13% over the past three years. While the costs to serve individuals continue to rise, funding available for that care continues to be decreased.

The Senate budget made two additional changes that impact education and tax revenue. The Senate put $61 million into public schools to reduce class sizes over the next 4 years, but eliminated more funds for teachers’ aides and other areas of public education. Eliminating funding for teacher’s aides is in addition to major cuts to early education and child development programs including Smart Start and the More at 4 Program, which helps at-risk children, including those with autism and other developmental problems, start school on pace with other children.

The Senate’s budget reflects reduced revenues from a tax package that allows the penny sales tax to expire and would reduce individual income tax rates by .25% and reduce taxable income for certain small businesses. The cuts to services that are important to the autism and DD community mentioned here could be restored if the state’s current revenue package were to remain in place.

The Senate will vote on its budget next Tuesday, May 31 and Wednesday, June 1. House and Senate Appropriations Committee chairs have been meeting over the past week to see if they can reconcile differences to pass a budget next week that both chambers agree on.

Get Informed!
The Autism Society of North Carolina has compiled a list of cuts relevant to people on the autism spectrum below. 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 for the Senate Appropriations Committee 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.

Act now to have your voice heard!

These cuts are unacceptable to the Autism community. The loss of IPRS funding means people with Autism Spectrum Disorder who have no other services and supports could lose what little they have. Continuing to cut Medicaid funds, including provider rates, means lower quality of care and less access to services. Children in mainstream classrooms would have less help, and fewer children would get the right start in school. Non-profit providers like the Autism Society of North Carolina would sustain cuts to nearly every aspect of their programming.

Contact your NC State Senator and tell them

• The cuts are too deep! Support using the House budget figures.
• Keep the penny sales tax and hold off on tax breaks; if they kept the sales tax, the cuts in the House and Senate budget could be restored.

How to Contact Members of the General Assembly:

• By phone: All legislative offices can be reached through the General Assembly switchboard by dialing (919) 733-4111.
• Legislators also have offices in their districts. For Raleigh and home district office contact information for Legislators visit the General Assembly’s “Who Represents Me?” page. Click on “House” or “Senate,” then look for Member Lists. Click on a name to find your legislator’s web page and contact information for their local offices. This is a 3-day holiday weekend, so you may be able to connect with your legislator while they are in their home districts.
• By e-mail: Legislative e-mail addresses can be located through the “Who Represents Me?” pages.
• For those without Internet access, local Boards of Elections can be asked for assistance.

Need more help in contacting your legislators? Click to view ASNC’s “How to Contact your Legislator” tip sheet.

Do you have questions about legislative and policy issues? Email Jennifer Mahan, ASNC Director of Government Relations, at jmahan@autismsociety-nc.org or call her at 919-865-5068 or 1-800-442-2762 ext 1116.

The Autism Society of North Carolina can’t advocate without you. Thank You for your continued support of our work.

Budget Cuts :House and Senate

	House Budget	House Budget	Senate Budget	Senate Budget
Department	Fiscal Year 2011-2012	Fiscal Year 2012-2013	Fiscal Year 2011-2012	Fiscal Year 2012-2013
DHHS Admin
Non-Profit Funding	(5,000,000)	(5,000,000)	(10,000,000)	(10,000,000)
CARELINE (handles calls for help, including Medicaid problems)	(380,478)	(380,478)	same	same
Div Child Development
Smart Start	(37,600,000)	(37,600,000)	same	same
Discontinue transport	(1,001,718)	(1,001,748)	same	same
Div of Public Health
Early Intervention	(3,500,000)	(3,500,000)	(3,118,046)	(3,118,046)
Div of Medical Assistance
Modify Optional and Mandatory Services (total of several)	(16,508,903)	(22,072,343)	(16,732,335)	(22,295,678)
Eliminate inflationary increases	(62,853,778)	(139,290,860)	(62,853,775)	(130,874,505)
Adjust provider rates	(46,400,000)	(46,500,000)	(71,420,718)	(71,420,718)
Behavioral Health 1915 b/c waiver (includes DD, autism)	(10,500,000)	(52,500,000)	same	same
CCNC savings(implementing more medical homes)	(90,000,000)	(90,000,000)	(83,071,581)	(90,000,000)
Modify and Eliminate optional Services			0	(51,474,609)
Div of Mental Health, Developmental Disabilities, Substance Abuse
Eliminate 7 advocacy positions (in state facilities)	(158,045)	(158,045)	same	same
Eliminate Community Funding (IPRS) for  Medicaid recipients, except residential support	(20,000,000)	0	(30,000,000)	(30,000,000)
Swap (LME) fund balance w/ state service funds	(25,000,000)	0	same	same
Reduce Division management flex funds (emergency fund)	(7,180,807)	(7,180,807)	same	same
Reduce LME mgt funds			(7,234,005)	(7,234,005)
Education
Public Schools Total Cuts	(694,040,243)	(670,358,180)	(696,788,009)	(732,011,651)
LEA adjustment (schools return funds to state, make cuts locally)	(346,914,388)	(410,440,688)	(4,365,359)	(65,292,506)
Eliminate TAs (except K-1)	(258,647,482)	(254,193,602)	(390,519,448)	(395,946,237)
Community Colleges Total enrollment growth funded, but tuition increased and all programs cut	(110,512,354)	(110,512,354)	(120,169,798)	(120,169,798)
University System Total enrollment funded, but 470 mil flex cut to be determined by UNC	(447,561,332)	(447,443,210)	(359,000,000)	(360,000,000)

 

House Budget Proposal Released, Includes 1915 b/c Managed Care Waiver

 

Budget: The General Assembly House Appropriations Sub-committees released their budget proposals and budget special provisions last week.  In most cases, sub-committees used the Governor’s budget cuts as a starting point and then cut an additional 1.6 billion dollars from the state budget for a total reduction of 2.5 billion dollars from the base budget. Cuts include $1.3 billion from public education, $527 million from Health and Human Services and $142 million from Justice and Public Safety.  The House budget proposal is $800 million below the projected revenue amount; leaving the possibility that additional tax cuts will be proposed along with the massive cuts to state services.

Overall, the cuts to developmental disabilities could have been worse, but the deep cuts to education, other human services and support services will result in services lost, jobs lost, and set the state back decades in its efforts to move forward in education, health and public safety. Budget writers have left millions on the table that can be used to take a more balanced approach.  Budget cuts that could impact people with autism spectrum disorder and other developmental disabilities are described below and a list of some specific line items follows. Because sub-committees are still making changes, some of the numbers below reflect recent changes in the document that may not yet be listed on the GA website.

Proposed Cuts: House budget proposals include $3.5 million in cuts to early intervention, $20 million in cuts to state funded service dollars, also called Integrated Payment and Reporting System (IPRS) funds which are administered at the Local Management Entity level to deliver services such as Developmental Therapies, and $25 million in IPRS service dollar cuts that are to be made up through the use of Local Management Entity fund balances. Medicaid was cut by $375 million. Some cuts are expected to be made up for with funds from the Federal government and use of “medical homes,”  which increase care coordination resulting in use of fewer and lower cost services. However, if the “savings” cannot be found, the North Carolina Department of Health and Human Services (NC DHHS) is authorized to reduce or eliminate optional Medicaid services. Cuts to Medicaid result in the loss of Federal matching funds at a $3 to $1 ratio.  Medicaid providers, except doctors and nursing homes, will not get inflationary increases and instead see a rate reduction in the range of 2%.  Included in House budget special provisions is language that would prevent anyone on Medicaid from receiving services funded by IPRS dollars, with the exception of those needing residential supports.

Another area of great concern is the massive cuts to education, including early childhood programs like Smart Start and K-12 education. While there is no specific cut to special education, these cuts will impact the availability of developmental and health screenings in local communities and educational support in primary education.  The cuts have the potential to result in the loss of 21,000 positions including teacher assistants and non-instructional support like guidance counselors and school psychologists, putting more pressure on teachers for children with ASD who are in mainstreamed classrooms. 

Managed care: The budget special provisions include language that expands 1915 b/c combination managed care waivers for people with developmental disabilities including ASD. Particularly troubling, the budget finds savings of $3.2 million in year one and $38 million in year two of the budget from the implementation of these waivers. According to waiver guidelines, savings are not to be removed from the system, but are to be re-invested in the system to provide better access to services and supports for those waiting for help.  The Autism Society of North Carolina is concerned that managed care waivers will move forward without public input, will eliminate independent case management, and will result in a loss of services for people with autism spectrum disorder rather than ensuring we reduce waiting lists. 

ACTION: The House budget will be voted on in the next week. Call, email or visit your Legislator to express your concerns!

1. Let your legislator know how budget cuts and managed care will impact you and your family.
2. Urge legislators to take a balanced approach to the budget and preserve vital services and supports, including education. 
3. Tell them that managed care needs to include public input, independent case management, a continuum of quality service and support options for people with autism, and protections for individuals’ rights. Savings should come from administrative efficiencies not reduction in services.
4. Attend Autism Awareness Day at the General Assembly on May 3^rd. Go to the ASNC website for more info and detail on how to register.
5. The General Assembly website at has info on who represents you. You can call the General Assembly  switchboard at 919-733-4111 to contact your Legislator.  

Budget Cuts by Department: This is not a complete list of cuts; for more info please see www.ncleg.net for specific budget line items. Cuts are indicated by parenthesis ().

Department	Fiscal Year 2012-2013	Fiscal Year 2011-2012
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	(3,500,000)	(3,500,000)
Div of Medical Assistance
Modify Optional and Mandatory Services (total of several)	(16,508,903)	(22,072,343)
Eliminate inflationary increases	(62,853,778)	(139,290,860)
Adjust provider rates	(46,400,000)	(46,500,000)
Behavioral Health 1915 b/c waiver (includes DD, autism)	(10,500,000)	(52,500,000)
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	(694,040,243)	(670,358,180)
LEA adjustment (schools return funds to state, make cuts locally)	(346,914,388)	(410,440,688)
Eliminate TAs (except K-1)	(258,647,482)	(254,193,602)
Community Colleges  Total enrollment growth funded, but tuition increased and all programs cut	(110,512,354)	(110,512,354)
University System Total enrollment funded, but 470 mil flex cut to be determined by UNC	(447,561,332)	(447,443,210)