Waiver OverviewWaiver Overview1915 (b) Medicaid Waiver Expansion

What Is It?What Is It?

• Waiver: a request to CMS that provisions of the Social Security Act be “waived”Social Security Act be waived

o State-wideness

F f i t i to Fee for service payment requirements

o “Any willing and qualified provider”

• Expansion of PBH pilot waiver (Cabarrus, Davidson, Rowan, Stanly, Union)Davidson, Rowan, Stanly, Union)

What Is It?What Is It?

• Combines services for all MH/DD/SA consumers into a single capitated funding consumers into a single capitated funding model

W i tit i k i i • Waiver entity assumes risk in managing services

• Combines authorization management of Medicaid, state and local funds at the community level

Benefits of 1915 (b)/(c) WaiverBenefits of 1915 (b)/(c) Waiver

• Predictable Medicaid Costs

• Maintains public infrastructure to manage MH/DD/SA services

• High quality standards/consumer outcomes

• Savings remain with waiver site and can be • Savings remain with waiver site and can be reinvested back into services

Abilit t i id t k t b t t • Ability to size provider network to best meet consumer needs

Benefits of Waiver for ProvidersBenefits of Waiver for Providers

More predictability in business relationships with p y pthe LME/MCO

Some flexibility in reimbursement rates in relationship to service needs, clinical priorities, etc.

Keeping funding and control for home and i b d i i h i i community-based services in the communities

services are provided

Benefits to ProvidersBenefits to Providers

Direct access to decision-makers – at LME, Board of ,Directors, etc.

The opportunity to participate in planning for services

Local Utilization Management responsiveness

Benefit to ProvidersBenefit to Providers

Locally managed access to assistance for consumers y gin crisis or needing medications Care Coordination

di Access Coordinators

Advocates and Community Relations Specialists

Empowerment to define and work together with LME/MCO and provider organizations to ensure LME/MCO and provider organizations to ensure overall system performance and accountability

Proposed LMEProposed LME--MCOs and “GoMCOs and “Go--Live” DatesLive” Dates

Piedmont Behavioral HealthAl /C ll

Went Live in 2005O t b •Alamance/Casewell

•Five County•OPC

•October 2011•January 2012•April 2012

Western Highlands Network January 2012Western Highlands Network January 2012

East Carolina Behavioral Health April 2012

Sandhills Center/Guilford July 2012

Smoky Mountain Center July 2012

TDC/Johnston/Cumberland/Wake January 2013

Eastpointe/Southeastern January 2013p /Regional/Beacon Center

y 3

Southeastern Center/Onslow-Carteret January 2013

CenterPoint Human Services January 2013CenterPoint Human Services January 2013

Pathways/MH Partners/Crossroads January 2013

Mecklenburg January 2013

What Does This Mean for TDC?What Does This Mean for TDC?

• The Durham Center has affiliated with Cumberland and Johnston Counties and Cumberland and Johnston Counties and intends to merge with Wake LME to far exceed minimum Medicaid enrollee standardsminimum Medicaid enrollee standards

• A merged Durham-Wake LME serving a four-county region including Wake would encompass a population of almost 1,690,000 residents, with approximately 186,000 M di id li ibl itiMedicaid-eligible citizens

What Does This Mean for TDC? What Does This Mean for TDC?

Working to ensure LME responsibilities are being g p gcovered while simultaneously working to develop MCO functioning

New Organizational Structure and Operations Likely one large Corporate Office centrally located between

Raleigh and Durham

Satellite offices to maintain local presence (e.g., Care Satellite offices to maintain local presence (e.g., Care Coordination)

TimelineTimeline Moving ForwardMoving Forward

Beginning 3rd Quarter, FY’12: Town Hall Meetings, Focus Groups, Provider Meetings, etc. will be held to provide updates, solicit input and feedbackfeedback January 2012

4th Quarter, FY’12– Notification will be sent to all providers billing Medicaid in the MCO coverage area regarding Credentialing Process and link to regarding Credentialing Process and link to application for credentialing and enrollment May 2012-Target for receiving applications

TimelineTimeline

July 1, 2012 – If approved, The Durham Center and Wake County LME’s will move forward as a merged LMECounty LME s will move forward as a merged LME

1st Qtr. FY’13-Provider Trainings for Waiver PreparationS i D fi iti d Cli i l C Service Definitions and Clinical Coverage

Person-Centered Planning and Crisis Planning under the Waiver Clinical Practice Guidelines with EBP

2nd Qtr. FY’13 – Mandatory Trainings for Contracted Providers Offered monthly, likely in day-long format Offered monthly, likely in day long format

January 1 2013: “Go-live” Date for MCO January 1, 2013: Go-live Date for MCO

CredentialingCredentialing

All Licensed Providers serving individuals with Cumberland, Durham Johnston or Wake Medicaid will be required to Durham, Johnston, or Wake Medicaid will be required to apply for credentialing and enrollment with the MCO Need to apply and be credentialed through MCO, even if credentialed or

re-credentialed through the N.C. Medicaid Program Need to apply and be credentialed through each MCO

Finalizing Credentialing Software currently and looking to g g y ghave a web-based application Allow for more timely processing and ability to immediately confirm

receipt of application

Providers must ensure timely response to MCO inquiries to complete credentialing process (e.g., missing information, conflicting information etc )conflicting information, etc.)

CredentialingCredentialing

Notifications for Credentialing will be sent directly to id i il d li i ill b il blproviders via e-mail and applications will be available

24/7 through the MCO website

Time frames for Credentialing will be communicated with the intention being having ample time to credential, enroll and extend contracts to providers well before enroll, and extend contracts to providers well before January 1st, 2013

Contracted Providers will make up the MCO Provider Network

Network DevelopmentNetwork Development

MCO must have providers in place to ensure access d d f ll ll Th d d f llstandards for all enrollees. These standards are as follows:

Measurement Standard

Psychiatrist/member ratio 1 Psychiatrists/1000 enrollees actively Psychiatrist/member ratio 1 Psychiatrists/1000 enrollees actively receiving services during previous 10 mo

Licensed Independent Practitioners (LIP) not including

4 LIPs/500 enrollees actively receiving services during previous 10 mo.( ) g

psychiatrist/member ratiog p

Percent of open Psychiatrists 60% Open

Geo. Distribution of Psychiatrists and 1 Open Psychiatrist and 1 other type of Geo. Distribution of Psychiatrists and LIP’s to each member

1 Open Psychiatrist and 1 other type of LIP within 45 miles/45 minutes (rural); within 30 miles/30 minutes (urban)

Geo. Distribution of CCP’s to member 1 CCP within 20 miles/minutes/

Geo. Distribution of residential facilities 1 facility within 100 miles/100 minutes

Behavioral Health Facility (inpt., crisis). 1 within 75 miles/75 minutes

Network DevelopmentNetwork Development

Submitting an Application for Credentialing will be the fi i b i k idfirst step in becoming a MCO network provider

All information regarding the credentialing application All information regarding the credentialing application, process, etc. will be covered in an upcoming All Provider Meetings

MCO ill h ld A li ti A i t S i li ti MCO will hold Application Assistance Sessions once application process has begun

Ideally will have a web-based application to minimize turnaround time when processing applicationstime when processing applications

We Need Your Help and Input!

What Can Providers Do to Get Ready?What Can Providers Do to Get Ready?

Ensure LME’s have most up-to-date location/s, p / ,contact information, etc.

Ensure insurance coverage is up-to-date

Stay in good standing with DMA

What Can Providers Do? What Can Providers Do?

Make sure licensed professionals have updated and p paccurate Curriculum Vitaes, licenses, certificates, etc.

If you have provisionally-licensed staff applying to be credentialed, be sure they have an up-t0-date and

t i i l fil ith th accurate supervision plan on file with the appropriate licensing board

Check DMA, DHHS, and other websites regularly

What Can Providers Do? What Can Providers Do?

If transitioning services, please notify the LME and g , p ydevelop a transition plan to ensure all individuals are connected to the most appropriate treatment and

d t d lrecords are stored properly

St i f d di E id B d P ti Stay informed regarding Evidence-Based Practices and continue to develop competencies

Ensure agency staff are aware of Waiver Process and able to respond to consumer concerns within reason able to respond to consumer concerns within reason.

What Can Providers Do? What Can Providers Do?

Attend Town Hall Meetings, Provider Forums, All g , ,Provider Meetings, etc.

Review other MCO Websites Across the State PBH- www.pbhcare.org

i hl d k hi hl d Western Highlands Network – www.westernhighlands.org

Ensure the most appropriate staff are on Ensure the most appropriate staff are on MCO/LME’s Mailing List – limit to 4 staff per agencyg y

What If I have Questions?What If I have Questions?

Waiver Frequently Asked Questions are in the process of being developed and will be posted on the LME website

h d h Share questions and concerns with your LME/MCO A Waiver Question/Comment E-mail will be set up shortly and

shared via Provider Newsletter

The Next All Provider Meeting will be in March, 2012 May look to establish monthly provider meetings regarding merger

with Wake County and Waiver