NC DHHS recently published a Request for Application (RFA) pre-release concept paper that
outlines the proposed requirements for the BH/IDD Tailored Plans. Legislation states that opportunities to be
BH/IDD Tailored Plans are only available to the LME/MCOs for the first four
years after the implementation of the Standard Plan. Legislation also established that the BH/IDD
Tailored Plan will go into effect no earlier than one year after the
implementation of the Standard Plan.
If the tentative start date for the BH/IDD Tailored Plans
for July 2021 were to stand, the Standard Plans would have to be implemented no
later than July 2020. The ongoing budget
impasse between the NC General Assembly and the NC Governor has left us with an
indefinite suspension of the implementation of managed care in physical
healthcare and that may require an adjustment of the go-live date for BH/IDD
Tailored Plans. Regardless of the actual
start date for the BH/IDD Tailored Plan, NC DHHS is moving forward on the RFA
process. As the concept paper shows,
there are a multitude of preparations and processes that must occur prior to
the implementation of BH/IDD Tailored Plans.
Dave Richard, Deputy Secretary for Medicaid, noted to legislators
recently that it will facilitate ongoing preparation to identify the BH/IDD
Tailored Plans and allow for focused work with awardees.
premises of the RFA:
regions are based on the current LME/MCO catchment areas, per recommendations
of the NC Association of County Commissioners and others.
the LME/MCO currently serving that region can apply to be the BH/IDD Tailored
Plan for that region in this round.
first contract period will be for the entire four-year period in which LME/MCOs
are the sole contractors (after that time, it will be bid competitively with current
BH/IDD Tailored Plans and non-profit Prepaid Health Plans licensed in North
there will be 5-7 BH/IDD Tailored Plans, therefore, there is not a guarantee
that every current LME/MCO will be a BH/IDD Tailored Plan.
requirements for BH/IDD Tailored Plans not only include those that were used to
award the Standard Plan contracts, but include additional requirements based on
the high-needs population being served.
structures such as the LME/MCO Board, the Consumer and Family Advisory
Committee (CFAC) and other advisory boards remain in place.
Tailored Plans will be required to develop and implement a Local Community
Collaboration and Engagement Strategy.
In addition, they are required to have or strengthen relationships with the
Department of Public Instruction and the Division of Vocational Rehabilitation
as well as the NC Housing Finance Agency.
BH/IDD Tailored Plan will subcontract with a PHP licensed in North Carolina and
it is not required that the subcontractor already be providing Standard Plan
services in that Tailored Plan region.
provider network for the Tailored Plan behavioral health and I/DD services will
be closed (as it is now) and the provider network for the Tailored Plan
physical health services will be open—any willing Medicaid provider.
adequacy standards will be in place. One
benefit is to ensure there is choice at the provider level to the greatest
and TBI Tailored Plan Care Management is further clarified to allow for the
Medicaid beneficiary to choose between the Tailored Plan Care Management or the
current care coordination service that the LME/MCO provides.
- Care management takes the whole-person approach
of coordinating physical, I/DD, TBI, BH, pharmacy and unmet health-related
- All eligible Medicaid beneficiaries will be
informed of these services and provided options that include care management by
an Advanced Medical Home + or a Care Management Agency.
- The current Community Navigator service is
replaced by the BH/IDD Tailored Plan Care Management and, therefore, will no
longer be offered when the Tailored Plans go-live.
a Contract isn’t Awarded in a Region:
- In the
event a contract is not awarded to the responding LME/MCO for a region, this
will be considered an “empty region”.
can answer several supplemental questions in the RFA that will qualify them to
be considered to take on counties of an “empty region”.
contracts for empty regions is handled according to the following: “In the
event that no Contract is awarded in a Region to the entity currently serving
the Region, the Department will, at its discretion, award all or part of the
“empty” Region to one or more qualified applicants, using an optional,
supplemental questions request”. The
paper further notes that there will only be one BH/IDD Tailored Plan in each
BH/IDD Tailored Plan is required to become licensed as a Prepaid Health Plan in
North Carolina 90 days before the end of the Contract Year 3 (it will require
legislative authority to require this),
with Standard Plan Requirements:
rate-setting methodology will align with the methodology used with the Standard
Tailored Plans, similar to Standard Plans, will have incentives to use savings
towards high-impact initiatives on health-related needs of their
Tailored Plans must use the same statewide formulary for pharmaceuticals that
the Standard Plans will use.
to Standard Plans, BH/IDD Tailored Plans will be required to have rate floors for
of services will be based on the Standard Plan requirements and will have
additional layers related to the high-needs populations being served under the
1915(c) waiver (Innovations) and the health home requirements.
Accreditation is required as it is for the Standard Plans and BH/IDD Tailored
Plans must additionally have that accreditation cover long-term services and
Tailored Plan Solvency and Risk:
Tailored Plan must meet an 88% Medical Loss Ratio (see below for further
DHHS is considering a shared risk with Tailored Plans in the beginning that are
structured through a “risk corridor” that would limit the amount of savings for
the Tailored Plan and also limit the amount of financial risk they take on.
BH/IDD Tailored Plan must have a risk reserve from the first day of go-live
that is equal to 12.5% of the annual capitation.
Care and Withholds:
DHHS will withhold a portion of the premiums paid to the BH/IDD Tailored Plans
which will then be paid to them retrospectively based on meeting performance
expectations in various areas.
DHHS acknowledges the need to move more slowly into value-based contracting
with the BH/IDD Tailored Plan population than they have prescribed for the
Standard Plan. Therefore, they are going
to begin with a focus on value-based care management under the Tailored
DHHS will develop value-based purchasing targets for BH/IDD Tailored Plans that
will begin in Contract Year 2.
measures will be used for NC DHHS to track whether there are improved outcomes
for members. (See pages 19-27 of concept
paper for measures). Contract Year 1, NC
DHHS will report the performance based on the measures.
performance measures will be identified.
Contract Year 2, NC DHHS will begin withholds on specific priority
Transition and Diversion from Higher Levels of Care:
- NC DHHS
will expand the use of in-reach, transition and diversion beyond the Transition
to Community Living Initiative to individuals residing in certain institutional
who will qualify for in-reach and transition include—
- Individuals with Severe Mental Illness who are
residing in an Adult Care Home or a state psychiatric facility;
- Individuals residing in an Intermediate Care
Facility for Individuals with an Intellectual Disability (ICF-IID) or a state
who will qualify for diversion include–
- Individuals who transitioned from an
institutional or correctional setting within the previous six months or are
seeking entry into an institutional setting.
- Individuals with an I/DD or TBI diagnosis whose
caregiver is unable to provide interventions before institutionalization, aging
or in fragile health.
- All children and youth with an I/DD diagnosis
and complex behavioral health needs.
and transition staff of the BH/IDD Tailored Plans are expected to have
competencies in the area of disability of that Medicaid beneficiary.
activities include: informing
individuals of their options to live in the community; addressing barriers and
challenges to their transition to the community; addressing concerns of
consumers and family members about transitioning to the community; creating
opportunities for consumers and family members to visit with peers who live and
receive services and supports in the communities; supporting facility staff in
activities include: assisting the
consumer and family in planning for community-based services and supports;
providing any training or technical assistance to the community-based providers
receiving this consumer; addressing barriers to transition; identifying funding
options to assist in the transition.
on In-Reach and Transition for Children and Youth–
- Children and youth who are in state psychiatric
hospitals, psychiatric residential treatment facilities (PRTFs) and certain
residential treatment levels will receive in-reach and transition
- Goals are set to reduce the average length of
stay, readmissions, and the number of youth in institutional or other
- BH/IDD Tailored Plans will be expected to
identify and engage children and youth members in transition services;
collaborate with facilities, community providers, and other youth-specific entities
or systems; ensure individualized, person-centered transition plans; identify
and address barriers to transition; and ensure warm handoffs and linkages to
community providers and care managers.
activities for all members eligible to move into the community and receive
community-based services include: screening
and assessment, education on options and supports available, referral and
linkage to services (including supported housing), a Community Integration
I HAVE A QUESTION OUT WITH
KELSI TO CONFIRM THIS TIMELINE
Proposed Timeline for Implementing of the BH/IDD Tailored Plan—what we know:
February 21, 2020:
Pre-Release of the BH/IDD Tailored Plan RFA concept paper comments due
Spring 2020: BH/IDD
Tailored Plan RFA is released. LME/MCOs
have 120 days to respond.
Late Summer 2020:
LME/MCO responses to RFA are due.
NC DHHS has certain
turnaround time to award contracts?
Readiness Reviews – Unknown
Late Fall 2020: NC
DHHS awards BH/IDD Tailored Plan contracts.
July 2021: Tentative
go-live of BH/IDD Tailored Plans.
is the Medical Loss Ratio?
Definition: Medical Loss Ratio (MLR) is a measure of the
percentage of premium dollars that a health plan spends on medical claims and quality improvements,
versus administrative costs.
Because NC DHHS is proposing an 88% MLR for the BH/IDD Tailored Plans, each plan will not be able to spend more than 12% of their capitation payments on administrative expenses.
OPEN MINDS article RFA Pre-Release Puts In Question Number Of North Carolina Tailored Behavioral Health Plans To Be Awarded for which i2i served as an Expert Resource.