Peter Freeman, MPH
Public Health Strategist & Senior Advisor
Despite the suspension of the rollout and implementation of Medicaid managed care in North Carolina (Medicaid Transformation), the North Carolina Department of Health and Human Services (Department) is continuing its attempts to streamline the provision of Medicaid- and other State-funded services. On December 30, 2019, the Department released a Medicaid Managed Care Policy Paper outlining how its Behavioral Health and Intellectual/Development Disability Tailored Plans will be asked to operate State-funded Services. In this article, we provide background on this policy, further explanation, and our analysis of the policy and its effects.
BACKGROUND
As part of Medicaid Transformation, the Department included three separate managed care products that would collectively address the needs of the State’s Medicaid and NC Health Choice recipients: Standard Plans, Behavioral Health and Intellectual/Developmental Disability Tailored Plans, and the Statewide Specialized Foster Care Plan. The Behavioral Health and Intellectual/Development Disability (Behavioral Health I/DD) Tailored Plans are the second product to be introduced and are intended to be implemented under the managed care model. Contracts will be awarded exclusively to a currently existing Local Management Entity – Managed Care Organization (LME-MCO). As such, the responsibilities of the Behavioral Health I/DD Tailored Plans echo those of the LME-MCOs, including:
- Providing services for Medicaid recipients with mental health, substance use disorders (SUDs), I/DDs, and traumatic brain injury (TBI);
- Managing behavioral health (e.g., mental health and SUD), I/DD, and TBI services for recipients of State-funded Services; and
- Coordinating and administering local health functions (e.g., Crisis/Involuntary Commitment, Disaster Emergency Response, Collaboratives, and Natural and Community Supports) in partnership with Standard Plans (as designed for Medicaid Transformation) and other stakeholders.
The focus of the December 30, 2019, Policy Paper is the State-funded and Local Health services that the Behavioral Health I/DD Tailored Plans will administer.
In addition to finding a permanent home for State-funded mental health, SUD, I/DD, and TBI services under Medicaid Transformation, the continued alignment of Medicaid, State-funded, and Local Health services currently assigned to the LME-MCOs is set to help the Department improve the entirety of these services. Per the Policy Paper, the Department expects the Behavioral Health I/DD Tailored Plans to:
- Promote consistency and equity in access to State-funded Services by those with the greatest needs;
- Focus the State-funded Services array on effective treatments that are based on best and/or promising practices consistent with Department priorities;
- Maximize the impact of limited State and federal funding;
- Further integrate Transitions to Community Living (TCLI) principles and functions; and
- Ensure the appropriate quality and oversight of State-funded Services.
PROMOTE CONSISTENCY & EQUITY
One of the first statements made by the Department in the Policy Paper is the acknowledgment that, there is “wide variation in how LME-MCOs administer State-funded Services” and, “current practices for determining eligibility, waiting lists for services, services offered, and copayments vary by LME-MCOs.” In response to this reality, the Department noted several aspects of ensuring recipients have consistent and equitable access to State-funded Services under the Behavioral Health I/DD Tailored Plan Model throughout the Policy Paper, including:
- Eligibility: The Department is committing to establishing and requiring the Behavioral Health I/DD Tailored Plans to all adopt the same criteria for determining a recipient’s eligibility to receive State-funded Services. These criteria will ultimately be decided by stakeholders convened by the Department and will be provided alongside guidance on how to implement them. The Department has already established certain income and insurance status criteria, including whether an individual has, is eligible for, and/or has applied for Medicaid services. This specific criterion also helps the Department maximize the impact of state and federal funding by ensuring each public dollar is allocated appropriately to provide for its intended service.
- Waiting Lists: Behavioral Health I/DD Tailored Plans will require their providers to submit waiting lists on a weekly basis. The Plans, in turn, will be required to submit waiting lists to the Department on a to-be-determined frequency. Providers will be required to stratify their waiting lists by disability and service, with the Plans needing to report to the Department by service, disability, and age. The immediate utility of the Waiting Lists will be to help the Behavioral Health I/DD Tailored Plans connect recipients on one provider’s waiting list with another provider who has availability. Moving forward, the Department intends to use all waiting lists to develop a statewide waiting list to help inform decisions and planning for State-funded Services.
- Services Provided: The Department will require all Behavioral Health I/DD Tailored Plans to provide the same suite of services to all recipients. The Policy Paper compares the services currently offered by the LME-MCOs with those that will potentially be offered by the Behavioral Health I/DD Tailored Plans. In general, the services remain largely the same, save that:
- In some instances, multiple LME-MCO services are combined into one plan service (e.g., Group Living and Family Living SUD services provided by LME-MCOs are to be known as Substance Use Residential Support services when provided by the plans); and,
- The plans will be responsible for providing at least six new services not currently on the LME-MCO roster. Recipients should be able to maintain access to their current services (or the equivalent of when applicable) after the transition to Behavioral Health I/DD Tailored Plans, assuming they continue to meet the definition of “medical necessity” required for those services. Relatedly, the plans will be unable to charge recipient copayments for any State-funded Service.
- Network Adequacy: Much like the requirement for Standard Plans, the Behavioral Health I/DD Tailored Plans will be asked to meet certain network adequacy standards to ensure access to care for recipients. In broad strokes, these standards will be related to time and distance standards (with distinctions made for urban and rural geographies), appointment wait time, and compliance with standards as established by the Americans with Disabilities Act. While specifics are not provided in this Policy Paper, we expect to see great similarities to those specifics outlined for Standard Plans.
What Atrómitos Hopes To See
Given the Department’s opening commentary on the current inconsistencies and variations across the current LME-MCOs, Atrómitos is in full support of the attempt to standardize a recipient’s ability to access care across the Behavioral Health I/DD Tailored Plans. In forthcoming documents and evaluation of the design, we will be looking for resolutions to:
- A lack of demographic stratification on Waiting Lists: As a Prepaid Health Plan (read: Standard Plan), entities are responsible for reporting quality and utilization measures across a range of demographics in order to identify and develop action plans to reduce health disparities. While health outcomes are an important part of assessing an infrastructure’s effectiveness, we would argue that paying attention to who is and is not able to access care is an integral factor in addressing disparities. The Policy Paper does indicate that Behavioral Health I/DD Tailored Plans will be required to address the cultural needs of their recipients, so it is concerning to us that the same array of cultural identities was not translated to the way in which Waiting Lists will be reviewed.
- Consolidation of required and optional State-funded Services: We are generally concerned about the potential negative impacts of consolidating multiple LME-MCO services into one new Behavioral Health I/DD Tailored Plan service. While we, again, fully support streamlining and developing efficiencies, the grouping of multiple services into one poses a number of challenges. Some questions we have are:
- How can recipients ensure they are appropriately being assessed for medical necessity?
- How will the Department ensure the plans are not silently ceasing the provision of a previously separate service under the LME-MCO model when reporting their new service category?
- Overlap in State-funded Service & Medicaid providers: In the spirit of streamlining, we hope to see the Department guiding the plans to ensure that State-funded Service providers within their networks are also Medicaid providers. At a minimum, we would expect Network Adequacy standards to require a certain percentage of the Network to be dual providers of these services. A payer offering multiple plans having overlap in their provider networks across products (as appropriate) can significantly reduce the risk of a patient falling out of care should they need to switch products as well as the plan’s burden of administering all products.
BEST AND PROMISING PRACTICES
The services provided by the Behavioral Health I/DD Tailored Plans will be required to meet, “the Department’s clinical service definitions.” The final list of which services will be required by plans and which will be optional to offer will be agreed upon by a Department-convened group of stakeholders. These services will be provided in partnership with, as appropriate, care management services. For care management services provided to recipients with an I/DD or TBI, the Department has laid out qualifications for Care Managers and those supervising them (see Table 3 on page 11 of the Policy Paper), including a requirement of previous direct service work with individuals with an I/DD or TBI for both levels.
What Atrómitos Hopes to See
We found the Policy Paper to be suspiciously quiet on how the Department intends to ensure State-funded Services are provided by following best and promising practices. In addition to the seven new services outlined in this Policy Paper (six in the covered services and one in care management), we anticipate that the Behavioral Health I/DD Tailored Plans may attempt to innovate in service delivery, as is a common practice under Medicaid managed care. A lack of clarification on what constitutes a “best” or “promising” practice may stifle this potential innovation and promote a status quo delivery of services to recipients. Additionally, the Department will be challenged to ensure it can prove that all services provided under these tailored plans are a “best” or “promising” practice, reducing the plans’ accountability to the Department.
MAXIMIZE IMPACT OF LIMITED FUNDING
Per the Policy Paper, State-funded Services will not see a change in where they receive funding upon the transition to a Behavioral Health I/DD Tailored Plan model. Given this, the Department was purposeful in highlighting multiple ways in which it was streamlining services to drive efficiencies. One way, as mentioned previously, is including an assessment of Medicaid eligibility as part of the criteria for State-funded Services. Another was to establish common qualifications of care management staff across State-funded and Medicaid Services. The Department is also interested in driving innovation by disbursing funds directly to providers for the purpose of piloting new models of care for some State-funded Services. However, the most significant efficiency established by the Behavioral Health I/DD Tailored Plan model is ensuring that the plans are pulled exclusively from the current LME-MCOs, thus leveraging a preexisting infrastructure and reducing the likelihood that State funds will be used for administrative development instead of for the delivery of services to recipients.
What Atrómitos Hopes to See
One of the driving forces behind North Carolina’s Medicaid Transformation efforts was the hope to control spending in the Medicaid program. As such, we support the Department’s goal of continuing to ensure each and every public dollar is used to its maximum potential for the services it was intended. However, we are concerned about the disbursement of funds by the Department directly to providers. We fully support providers having the flexibility to innovate and propose new ways of providing care. We also recognize the reality that in other Medicaid markets, dollars intended for providers, but paid by plans, have been rolled into the plans’ administrative overhead and therefore never find their way to providers. That said, we do not feel it is necessary in this instance to separate the oversight of potential provider innovation from the tailored plans. In fact, we find that giving the Department responsibility for managing this type of provider-level activity directly challenges the idea of maximizing public dollars spent on State-funded and Medicaid Services.
INTEGRATE TCLI
The Department expects the Behavioral Health I/DD Tailored Plans to continue the provision of TCLI services as the LME-MCOs currently do. The Department will retain its responsibility for identifying those eligible to receive TCLI services and ensure those services are appropriately provided by the tailored plans. Services the tailored plans are responsible for will include:
- In-reach and transition for adults;
- In-reach and transition for children and youth; and,
- Diversion from institutional settings.
What Atrómitos Hopes To See
The overview of TCLI services to be provided by the tailored plans was lacking in two major ways and brought to light two questions:
- How does the Department intend the services to be different from/remain the same as those provided under the current system?
- How, if at all, will services for Medicaid recipients differ from those provided to recipients of State-funded Services? We do not anticipate the differences to be many, or perhaps significant at all, but we hope to see a more comprehensive review of how the TCLI may or may not be evolving.
QUALITY AND OVERSIGHT
The Behavioral Health I/DD Tailored Plans will have three main categories of data to report to the Department:
- Eligibility and income of recipients;
- Service utilization; and,
- Financial information on the utilization of block grants and state funds.
Additionally, these tailored plans will be held responsible for a slate of quality metrics unique to the needs of State-funded programs and their recipients. Full details on the quality and oversight are not provided in the Policy Paper, but the Department does indicate it will work with the tailored plans on developing a quality improvement program that is based on data and outcomes.
What Atrómitos Hopes To See
We were disappointed in the single page allotted to the quality and oversight the Department will hold over the Behavioral Health I/DD Tailored Plans. Given the rich history (for better or worse) the LME-MCOs have in North Carolina, we hoped the Department would provide more robust details early on regarding their intent and infrastructure to oversee the transition of an LME-MCO to a tailored plan and their capabilities post-transition. We also have concerns about these tailored plans, which run the risk of having to report multiple types of data to varying parties within the Department. Inefficient use of the public dollar is the administrative burden of too many reports to groups within the same entity who do not communicate with each other; in support of its own goal, we hope to see the Department streamline its internal systems to reduce this burden on these plans.
CONCLUSION
Based on this Policy Paper, there are still some crucial details to be worked out for a smooth transition into providing State-funded Services through Behavioral Health I/DD Tailored Plans (though we appreciate the information the Department has provided thus far); we anticipate some answers coming in the forthcoming Request for Application (RFA) and associated Policy Paper. However, there is one question we will not get resolved in a Policy Paper: What did the State gain and lose by only allowing current LME-MCOs apply to be a Behavioral Health I/DD Tailored Plan?
If you or your agency is interested in further discussing the implications of this Policy Paper, please contact us now.