Medicaid Transformation- National Perspective- North Carolina View

- Understanding It - Educating/Advocating to effectively

shape it

Barbara Brent, NADDDSFirst In Families of NC staff:

(Interim Facilitators Jan.-March 2016) Kelly Friedlander, Local Facilitator

NC Stakeholder Engagement Groupinfo@ncseg.com

919-330-0777, ncseg.com

What’s Happening with Medicaid?

The way Medicaid and Medicaid-funded programs are managed is changing in North Carolina and throughout the US.

What’s happening nationally?

What’s happening in NC?

How can you advocate to effectively shape our new system?

Medicaid: A Growing Piece of the Puzzle for individuals needing long term support services (LTSS) or who have complex support needs

National Trends in Response to Medicaid Transformation

States are finding ways to address demographic realities and move forward to support person centered and family centered supports with increased flexibility targeted to a good life in the community for both individuals with disabilities and their family members.

•Supporting Families•Relationship-based supports, housing innovations & partnerships•Employment and other meaningful engagement services in the community

•More and better in home supports and services (new HCBS defs)•Capped support (and comprehensive) waivers •High intensity support coordination/case management with understanding of community, families & individuals

National Trends in Response to Medicaid Transformation (cont.)

Managed Care is growing, particularly in behavioral health and acute care.

There is some growth of the inclusion of I/DD and physical disabilities, particularly in home and community based, long term services and supports beyond medical and recovery.

A Common Goal: Supporting People to have Real, Meaningful Lives

Growing national consensus on:•Person – and family – centered approaches to support;•Recognition that people with disabilities are not one dimensional;

•Recognition that supports must consider the whole person, and

•Measuring outcomes is key to continuous improvement

Besides Being a Valued Goal - it is the Law

The Centers for Medicare & Medicaid Services (CMS), which funds most of the services (states match dollars) passed new, final rules in January 2014 for Home and Community-Based Services (HCBS). These rules require HCBS settings to provide opportunities for participants to engage in community life, have access to the community, control their personal resources, and seek employment and work in competitive settings. The purpose is to enhance the quality of HCBS, provide additional protections to participants, and ensure that individuals receiving services through HCBS programs have full access to the benefits of community living. HCBS Sets: ● What is NOT community● What is likely not community● What is community

Person-centered planning● Specifies requirements for planning (both process and content)Many states have much work to do! Day services? Residential? What changes need to be made in managed care?

The law applies to HCBS services in managed care and the new proposed managed care rules offer even more

protections.

States are Exploring Many Potential Paths

Integration is welcomed; but what does it mean?

Integrated, person-centered, holistic approaches to health and support services are growing…but the terms themselves may vary in meaning:Integration of Medicare and Medicaid● Many individuals with complex health and social support needs are

eligible for both Medicare and Medicaid.Integration of health care, mental health and substance use services and long term services and supports

● Many systems of care (both at the state and local levels) are recognizing that understating the whole person can impact outcomes.

Integration in the Community● Individuals, regardless of their support needs, should be supported

in and be supported to contribute within their communities.

And the second integration (health, mental health, substance abuse) is gaining more traction than I/DD or some physical disability communities

What is needed for Managed Care to be Successful?

Focus on Employment, In-Home Supports and Services AND Family Support:• Support Families to Envision a Good

Life• Support Family and Peer Networks• Provide information and Navigation• Design supports to be flexible and

responsible• Understand the impact on policies for

ALL families.

And Managed Care entities need to focus on…

The Individual will achieve self-determination, interdependence, productivity, integration, and inclusion in all facets of community life

Families will be supported in ways that maximize their capacity, strengths, and unique abilities to best nurture, love and support all individual members to achieve their goals.

“A Good Life for All”

MCOs Must Learn and Understand the implications related to:Services for people with I/DD can start in early childhood and last for a lifetime, unlike services for people that are seniors, and while some services are intermittent and intensive, many are ongoing.

This makes service planning and cost planning unique compared to MCO planning for other populations. Services are not primarily medical over a lifetime.

Does everyone have to live with their family?

No…it means we must:• Focus on supports for those

living in the family home where it is working and it is what people want

• Maximize an array of support strategies beyond only depending on 24 hour residential models.

• Recognize the contribution and importance of family members in the lives of members with a disability that live outside of the family home.

Assistance is needed in Developing and Integrating Supports and Services

Person or family resources, abilities, strengths, characteristics

Family, friends, neighbors, co-workers, community members, church members.

Disability Services, Special Education Medicaid, Housing, Food Stamps, Vocational Rehab (VR)

iPad, smart phone apps, remote monitoring, cognitive accessibility, adaptive equipment

School, businesses, Church/faith-based, public transportation, parks and recreation

What rings true for I/DD often is true for people with MH needs (and vice versa)

Individuals with Mental Health needs

The language is sometimes different but the emerging trends are quite similar:

• Person-centered approaches to care and support

• Improving options when individuals need residential support

• Increasing home and community-based options

• Increasing relationship-based options; including peers

• Improving quality and availability of crisis supports

• Ongoing care coordination/support

Think support coordination and think employment!

States are Using More than Managed Care in their Medicaid change approach:

Existing and Emerging ToolsMedicaid has many options states are exploring, some old, some new.

• Section 1915 (c) HCBS Waivers

• Section 1915 (i) HCBS as a State Plan Options

• Section 1915 (k) Community First Choice Option Health Homes

• Managed Care Authorities

• Comprehensive demonstration programs (1115s)

Managed Care Long Term Support Services (LTSS) across the U.S.

Arizona 1115 (DDD is MCO) includes HCBS, medical and behavioral health-govtMichigan (b/c) BH and IDD –gov’tWisconsin (b/c) all pops-both gov’t and private- but change is in the windKansas -all pops but behavioral health carve out- did not go smoothly with I/DD and significant delays - 1115, private MCOsNew Hampshire-1115 private MCOs- I/DD significant delays-will roll out at some pointTexas 1115- private all pops, DD carved out but will pilot with gov’t soon

In planning states• Tennessee has had other

populations for years, but I/DD to roll out soon with a focus on in home supports and employment

• Iowa about to roll out all populations but CMS delay

• Illinois in planning stages• New York (b/c) pre implementation• Louisiana and some other states in

exploration

And, of course, North Carolina!

Some exceptions to watch/learn from:

• Alabama is being blocked;

• Iowa- nobody wants to go to managed care;

• Michigan- starting health homes but not for IDD/MH/SUD

• New Jersey initially carving out most people and keeping

1915 c;

• Pennsylvania- more than a little exciting!

• Virginia carving out I/DD

• Arizona: some demonstrations with behavioral health

and acute (health)

States must support providers during any transformationChallenges Facing Provider Agencies

• More formal & complex contracting processes• More complex billing practices – clean claims,

encounters, codes – providers need assistance• Can have more licensure/credentialing requirements –

even for services/supports that are non-clinical in nature • Need better understanding of prior authorization and

related constructs• Need for more sophisticated data and analytic capacity –

for payment, to make a case of increased rates, incentive payments or to show increased authorization needs for people.

• More extensive contract requirements• Operational changes to meet MCO contractual

provisions – and working with systems partners to ensure person-centered outcomes and requirements

What about North Carolina?

NC House Bill (HB) 372: Medicaid Transformation & Reorganization

● A brief History: How did we get here?

● The Details: What does HB 372 do?

● The Timeline: When will this happen? (this Bill not yet approved)

● The Opportunity: How can advocates shape the future system?

NC SEG Member Matt Potter speaks at the Medicaid Reform

Advisory Group meeting in January 2014

February 2013

DHHS issues a Request For Information (RFI) asking for input on Medicaid system-this means people (mainly companies were asked to share their ideas and concerns)

Mid-March 2013 DHHS receives approximately 160 responses to RFI

April 2013 Gov. Pat McCrory and Secretary Wos unveil “Partnership for a Healthy North Carolina” 

● Goal was to have new system in place by July 2015May 2013

Secretary Wos tours the state to gather feedback on the new plan

The History: How Did We Get Here?

2013 Legislative Session Legislature does not agree on a Medicaid Reform plan.

November 2014 Medicaid Reform Advisory Group formed

February 27, 2014 Medicaid Reform Advisory Group presents their Medicaid plan

2014 Legislative Session Legislature does not agree on a Medicaid Reform plan.

House & Senate have very different

visions of Medicaid’s future

The History: How Did We Get Here?

The History: How Did We Get Here?2015 Legislative Session

● Budget negotiations held up for months ● Budget finalized close to 12 weeks after state mandated deadline of

July 1st

● House Bill 372 ● Filed March 26, 2015● Passed on September 22, 2015

● The Senate ● 33 voted it for it and 15 voted against it● less than five minutes of debate--this is fast!!!

● The House ● 65 for - 40 against ● One hour of debate - also very fast!!!

● Signed by Gov. Pat McCrory on September 23, 2015

The purpose behind HB 372

The theme of HB 372 is to reform

Medicaid by moving it from a fee-for-service

model, to Managed Care, primarily to

control costs.

The Details: What structure is proposed in HB 372?

• Combines the Senate’s and House’s preferred plans: providers can form their own managed care regional entities.

• The state will solicit bids from three commercial entities to provide care across the state, with three to five year contracts to stagger implementation.

• Up to 10 contracts will be awarded to regional, Provider Led Entities (PLEs).

• The state will be divided into 6 care regions.• At least two providers will offer care in each

region, with the idea to give Medicaid beneficiaries choice and create some competition between providers.

• The bill calls for the creation of a Division of Health Benefits to replace DHHS’ Division of Medical Assistance, the part of the department that currently runs Medicaid.

The new managed care entities will serve Medicaid-eligible people’s acute care (physical health) needs

Exceptions:• Dual Eligibles - people who

are eligible for both Medicaid and Medicare, the health care program for seniors and people with disabilities.

• Dental care will continue to be provided on a fee-for-service basis.

For at least the next four years individuals receiving behavioral health services (MH or IDD or SUD) will continue to receive their care through existing LME-MCOs.

The Details: Who is covered by HB 372 ?

The Timeline: When Will This Happen? ● DHHS to report to Legislative Oversight Committee on Medicaid

and Health Choice due on March 1, 2016.● Update! As of today…

● Bill requires the state send the detailed plan to the Center for Medicaid and Medicare Services (CMS) by June 2016. It is referred to as the 1115 waiver.

● Public Comment period (CMS requires at least 2 events) will start ~ March 15th;

● CMS approval will most likely take at least 18 months, and possibly two years. Some parts of the waiver may approve quickly, others can take more time. The bigger the changes, the longer it can take.

The Timeline: When Will This Happen?

● Managed care contracts will begin 18 months (or more) after CMS approval and when the state feels confident all is a “go”.

● LME-MCOs and their provision of all behavioral health services are “carved out” (not included) for at least four years after managed care contracts are implemented, then possibly for another four year extension.

● Behavioral Health Services= public mental health, intellectual/ developmental disability and substance use disorder services 

Public comment and input may alter the final design of the 1115

Other “Wild Card” Factors: Elections and Medicaid Expansion

Bottom Line: It’s Going To Be A While Before All is Worked Out

● Various, powerful stakeholders will be at the table● Private Managed-Care

Organizations● Elected Officials● Hospital/Medical

Associations● Senators & Representatives● Healthcare Non-Profits ● Associations and Providers

ANDYOU: cross disability consumers and family

members

The Opportunity: What Can Advocates Do?

“We have an opportunity to make a significant change in the future of health care. If we get it right – if we get it right

together – then we’ll have a chance to look back and say, ‘This has made a difference.’”

- Dave Richard, Deputy Secretary Division of Medical Assistance

A Challenge for Advocates

● Disability populations often silo-ed in their advocacy/education efforts and this can be particularly true in cross disability efforts;

● Consumers and family members are under-represented in the policymaking process;

● When invited, consumer and family members are often:

● Not adequately prepared ● Do not have a common set of

agreed upon principles or values to educate and advocate for.

Despite the Challenge

The system is rapidly changing and the involvement of consumers and families is more important than ever.

How can we have a greater impact together rather than acting in silos?

About the NC SEGA backbone entity with staff and a specific set of skills to serve the entire SEG initiative and coordinate participating organizations and agencies.

• Cross-disability advocacy initiative• Focusing on shaping long-term

support and service through meaningful engagement and dialogue with policymakers

• Consists solely of individuals receiving services and their family members

• Works in collaboration with DHHS

Common Agenda

All participants have a common agenda for change including a shared understanding of the problem and a joint approach to solving it through agreed upon actions.

Outcomes & Expectations Report

● 5 Outcomes● 12 Expectations

Common Agenda: 5 Outcomes of a Successful North Carolina MLTSS System

1. All eligible people receive services and supports they require - no waiting list

2. Everyone works in integrated community employment at competitive wages, with the supports necessary to be successful

3. Everyone is able to develop personal and financial assets4. Everyone lives inclusively in the community, in housing

that is not segregated by disability, with people of their choice, and with active participation in his/her community

5. The system is continuously accountable (achieves the desired outcomes and is transparent to the public) by involving consumers and families in its design, development, oversight, and evaluation 

Common Progress Measures

● Collecting data and measuring results consistently across all the participants’ disability areas ensures alignment and accountability.

Outcomes & Expectations Scorecard

A tool organizations or individuals can use to see how well a policy aligns with the NC SEG’s Outcomes & Expectations for MLTSS

Mutually Reinforcing ActivitiesA plan of action that outlines and coordinates complementary activities by each participant.

● Examples:● Increasing consumer and family

members participation in government

● Writing letters and presenting Outcomes & Expectations Report to Secretary Brajer

● Presenting at the Medicaid Reform Advisory Committee Meeting

● Providing written comments on rules, regulations, etc.

● Meeting with elected officials

“Spending the afternoon with the Stakeholder Engagement Group was an

invaluable experience for me. While their members got a chance to sharpen their

legislative advocacy skills, I got an opportunity to hear directly about what we need to do to make life more livable

for our citizens with disabilities.” – Senator Jeff Jackson, District 37

Communication

• Open, communication among many players to build trust, assure mutual objectives, and assist others in understanding why the Outcomes and Expectations will make a positive difference for multiple organizations and groups.

• SEG members promote the Outcomes & Expectations among all member’s networks

Who agrees?

● The “NC Outcomes and Expectations for Managed Long Term Services and Supports Report” has been endorsed by:

•NC Council on Developmental

Disabilities•Oxford House

•The Developmental Disabilities Consortium

•First In Families of NC

•The Power of The Dream

•Disability Rights NC•State Consumer &

Family Advisory Committee

•NC Consumer Advocacy, Networking

and Support Organization

•Smokey Consumer & Family Advisory

Committee – Central Region

•NC Substance Use Disorder Federation

•Alcohol & Drug Council of NC

•NC Statewide Independent Living

Council•National Alliance on

Mental Illness NC

Advocacy and Education Moving Forward

Align your personal/group advocacy messaging with a common voice for the greatest impact

● NC Outcomes and Expectations for Managed Long Term Services and Supports Report

● The Coalition “3 Goals” white paper aligns well with the SEG Outcomes and Expectations

Educate other individuals with disabilities and their family members so they can more effectively engage in systems change activities

● Materials posted on NCSEG.com● The NC SEG can provide informational presentations to

various groups/organizations

Advocacy Moving Forward • Stay involved in current advocacy work

• LME-MCOs, task forces, workgroups, etc.• CFACs• The Coalition• The DD Consortium; Mental Health Coalition; Substance Use

Disorder Federation and their member organizations

• Be specific; why the Outcomes and Expectations; provide examples; show why they matter; pick one that makes a difference to you or that the group you are speaking with is passionate about.

Stay ActiveManaged Care won’t be built in a day...

• Although LME mergers on hold for now; and LMEs (& all behavioral health services) “carved out” for next 4-8 years, stakeholders still need to pay attention:

• Attend Listening Sessions for Innovations Waiver

• Learn more about the new DD Caucus being set up in the General Assembly

• Learn how people’s Health issues are impacted by system change and how to influence

Whether in the new system or now, there are many additional specific activities SEG and others can do to help?

What can you take on as your issue(s)? For example:• “Medical necessity” for LTSS should not be based solely on THE score or THE uniform

assessment and instead includes a review of family context- - a person could have the same score but live in a home with a single parent with five other siblings. How can the SEG and others educate/advocate for best practices/?

• Generally managed care organizations have worked short term with people. Families are in there for a lifetime. How can you help them design the program and training with this in mind?

• Families must help write or at a minimum, independently review policies. People with disabilities and families must help provide training to MCO staff, providers, case managers/support coordinators- especially in the shift to managed care.

• Initial contact with system (i.e. intake process) should take place in the person and/or family’s home. That is the expectation in HCBS/LTSS but not currently uniform practice.

• Influence legislation….

Get READY to Vote●Make your voice heard.

●Your local elections are very important. These are the people who will be making decisions for NC.

●Research your candidates, talk with them, ask questions!●Then hold them accountable!

●Learn about how the NC Voter ID laws might impact you or your family members: http://voterid.nc.gov/

●Voter registrations due 25 days before the election●For more on registering to vote (deadline passed for

March 15th primary) http://ncvotered.com/register/

Get Out and Vote● Vote in the General Primary on March 15th

● The General Primary is where you can vote for Presidential Candidates in your party. Other referendums will also be on the ballot.

● Vote in the Congressional Election on June 7th ● Due to redistricting Congressional Elections have been

postponed until June 7th● For more information on voting accommodations visit: http://

www.disabilityrightsnc.org/voting● To find your polling location: http://ncvoterguide.org/answers/● A comprehensive view of recent voting changes and what they

mean to you:● http://www.wral.com/q-a-2016-changes-to-congressional-distri

cts-and-other-elections/15406485/

Stay tuned for: Stakeholder ToolboxThe NC SEG toolbox will contain useful information for advocates including: -the basics of managed care;-what stakeholders should expect from:State agenciesMCOs-suggestions for Stakeholder engagement in policies, procedures and oversight initially in systems design;-ongoing tips, tools, report cards, measures, design strategies, readiness, contracts, policies, network development and adequacy, innovation and leadership. Sign up at www.ncseg.org to be notified when tools are added!

“I'm amazed by the hard work, results and vision of our group. The NC SEG brought

individually marginalized stakeholders together and demonstrated that together we have a powerful voice throughout our state.

We have the experience, skills, empathy and common sense needed to help inform policymakers about what is needed to

achieve our common goals. We're a lovely group of people to spend the day with -

and we vote.” - Jackie Darling, NC SEG Member

Questions? ● Share our materials with others. Educational materials can be

found on our website at www.ncseg.com/stakeholder-tools.html

● Join our mailing list at www.NCSEG.com

● Like us on Facebook at www.facebook.com/NCSEG

● Have a group you are affiliated with endorse our Outcomes & Expectations Report; e-mail info@ncseg.com for information

● Collaborate with us in some other way! Contact the local facilitator at info@ncseg.com to share your ideas