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 31st 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 31st at 10 AM, where we expect House Bill 916 will be heard.

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One Response

  1. […] 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 […]

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