January 31, 2019

Tailored Plan Care Management Becomes Clearer

On January 24th NC DHHS held a webinar that provided additional, point-in-time information on the planning for the BH/IDD Tailored Plans. It was explained that these are initial discussions and that there will be further detail as planning progresses. NC DHHS will continue to offer webinars and other learning opportunities as well as concept papers as plans progress so this is a transparent process. It was also stated that the Standard Plan will be used as a part of the framework for the BH/IDD Tailored Plan to ensure some alignment.

Topic Areas of Discussion

[As a listener on the webinar, below is our understanding of the discussion.]

What is the general current thinking about care management in the BH/IDD Tailored Plan?

• There will be an integrated care management role. This is a new model for the BH/IDD Tailored Plans with a holistic approach.
• There will be a single care manager for every Medicaid beneficiary in the BH/IDD Tailored Plan. There will be an emphasis on local care management in order to coordinate unmet service and resource needs.
• Care managers are required to be certified by the State and may be Advanced Medical Homes that also serve individuals under the Standard Plans.
• The BH/IDD Tailored Plans will be able to respond to questions regarding individual plans of care.
• There will be one toll-free statewide phone number for more general service questions.
• There will be some services such as dental, local education agency and child developmental service agency work that will continue to be done under fee-for-service.
How will the care management function differ from the current system care coordination function?

There are several points of distinction between care management and care coordination:
• NC DHHS plans to use the framework of the Standard Plan care management role, including the Advanced Medical Home.
• The BH/IDD Tailored Plan will also include components of the national model of the Behavioral Health Homes.
• The care manager is responsible for assisting the Medicaid beneficiary in his/her needs across the spectrum of Medicaid services—including physical health, behavioral health and I/DD services—as well as assisting the beneficiary with the Social Determinants of Health such as housing and food insecurity.
• The Multidisciplinary Team will include a whole-person approach. So it may include pharmacy, social service, community human service agencies, along with the care manager and providers of physical healthcare, behavioral healthcare and I/DD services.
• Social Determinants of Health will be addressed through the care management role.
• Every Medicaid beneficiary under the BH/IDD Tailored Plan will be assigned a Care Manager.
• The care management role under the BH/IDD Tailored Plan is not based on episodes of care. It will instead be an ongoing connection with the Medicaid beneficiary.
• The care management role design elements are still be worked out. This includes the components of training that will be needed for care managers.
• The responsibility for ensuring that the components of integrated care, including care management, are met will be with the managed care organizations and LME/MCOs. There may be greater challenges in more rural areas of the State in ensuring this integration.
Can consumers keep their current doctors?

• The provider networks of the managed care organizations for the physical healthcare of Medicaid beneficiaries, under the 1115 Medicaid waiver, is open. This means that any willing provider who agrees to the rates available may be included in the network. Presumably, that will allow individuals to remain with their current provider but it will require the provider to formally be accepted into the network.
• There is a provision in State Law 2018-48/H. 403 that maintains the closed provider network for BH/IDD services managed by the LME/MCOs under the BH/IDD Tailored Plans.
Can decisions on services made by the Multidisciplinary Teams be overridden by the consumer?

Care managers, who will manage the Multidisciplinary Team process, will be trained to be person-centered. The service will have to be medically necessary for that individual Medicaid beneficiary. At all times, consumers have the ability to appeal decisions on their service plan.
Is member services a separate role or is that role with the managed care organization?
Each managed care organization will have member services responsibilities.

What are some of the upcoming logistical things we can expect in the Medicaid Transformation?

• Awards for the Standard Plan will be announced the week of February 4th.
• Enrollee assignments to managed care organizations in the Standard Plan will begin to be made this summer for those areas that will launch the Standard Plan in November 2019 and will begin to be made by October 2019 for those areas that will launch the Standard Plan in February 2020.
• BH/IDD Tailored Plans will be launched around July 2021.
• Populations covered by LME/MCOs will be reduced to those Medicaid beneficiaries who are expected to be in the BH/IDD Tailored Plans beginning in November 2019 when the first launch of the Standard Plan occurs. Medicaid beneficiaries eligibility to the Medicaid program will not be impacted by this shift.
New concept papers and materials from webinars are on the NC DHHS Medicaid Transformation/BH/IDD Tailored Plans webpage. To follow NC DHHS on this topic go to: https://medicaid.ncdhhs.gov/behavioral-health-idd-tailored-plans.