Special Medicaid Bulletin on b/c Waivers

Good Afternoon,

Please see the Special Medicaid Bulletin on the 1915 b/c waivers posted today. Please share with your stakeholders.

http://www.ncdhhs.gov/dma/bulletin/pdfbulletin/0113_1915bc_waiver_expansion.pdf

Thanks.

Kelly Crosbie, LCSW
Chief, Behavioral Health Section
Clinical Policy & Programs
Division of Medical Assistance
1985 Umstead Drive
2501 Mail Service Center
Raleigh, NC 27699-2501
(919) 855-4293
kelly.crosbie@dhhs.nc.gov

Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be disclosed to third parties by an authorized State official. Unauthorized disclosure of juvenile, health, legally privileged, or otherwise confidential information, including confidential information relating to an ongoing State procurement effort, is prohibited by law. If you have received this e-mail in error, please notify the sender immediately and delete all records of this e-mail.

10,000 Blog Views! and Counting...

This week, the blog reached 10,000 page views! North Carolinians (and others across the country) are watching - and inquiring minds wanna know...

At the time of the June 16th posting, the blog had reached 5,683 since February of 2012, when first launched. Since that time, the hits have more than doubled from viewers in at least 63 counties across the State of North Carolina and beyond. 

Once more, I'd like to point out that regarding total hits, the number (10,143 as of this posting) reflected to the right of the page (previously located at the bottom) is the correct total of page views since the initial launch of this parent / public information blog back in February of 2012. StatCounter was installed in May, so the data you see compiled via the blog's StatCounter statistics only reflects activity from May onward, mostly because I just haven't bothered to change it. 

Viewers include loads of parents / family members as well as provider agencies and professionals, LME / MCOs, universities and research groups, risk management groups, PR firms, law firms, advocacy organizations, and both state and federal government offices (*although due to the ambiguity of government IP data, it's impossible for a novice like me to know which specific offices nor even agencies are viewing)...

Some of the more interesting regular (and some once or twice) NC viewers include: Duke University, UNC Chapel Hill, UNC Charlotte, the Department of Veteran Affairs, the North Carolina Research and Education Network, Disability Rights NC, The Arc of NC (and various county chapters), NC Justice Center, NC Council of Community Programs, Crossroads Behavioral Healthcare (now Partners Behavioral Health Management), Daymark Recovery Services, Piedmont Behavioral Health, Sandhills Center, Saguaro Management and Accounting Services, Inc. (providing billing, human resources, program development and quality and risk management to human services companies), the Mental Health Association of Forsyth County, Raleigh's Campaign Connections PR firm, and numerous NC Government offices and agencies around the state.

And beyond North Carolina's borders: Kansas Health Institute, Virginia Commonweath University (VCU), Minnesota State Colleges and Universities, University of Georgia, Emory University, DC's American University, FHC Health Systems, Hospice of the Western Reserve in Ohio; Charleston, SC's New Hope Treatment Centers; HMS (a public government and managed-care contracting company); Deloitte, Marsh USA, and Alvarez & Marsal (each being US consulting / risk management firms with varying specialties); Nelson Mullins Riley & Scarborough LLP,  Drinker Biddle, and Hunton and Williams (each are national / multi-state law firms); and yes, even the US Centers for Medicare and Medicaid as well as a few hits from US Government offices in Washington, DC.

Yep, as election season launches into full swing (or sling as is oft the case), the world IS watching to see what North Carolina will do with it's special populations -- even if the usually less-than-enthusiastic main-stream media assignments and focus generally fall short in the real-life, human interest for "those people" and their families - because let's face it, nobody really wants to talk about what they don't understand, especially if it makes them sad... 

The 38th Vice-President of the United States, Hubert H. Humphrey, once said oh-so wisely, "The moral test of government is how it treats those who are in the dawn of life... the children; those who are in the twilight of life... the elderly; and those who are in the shadow of life...  the sick... the needy... and the disabled."

It's one of my favorite quotes and oh-so-fitting... and if you happen to be a quote-y kind of person like me and enjoy wise words, here's another for ya...

"Open your mouth for the mute, For the rights of all the unfortunate. Open your mouth, judge righteously, and defend the rights of the afflicted and needy." --Proverbs 31:8-9

So rest assured North Carolina, Inquiring Minds DO Wanna Know.

And to all the blog followers, the advocates, the exhausted parents, supportive family members; loyal and dedicated direct care staff, Case Managers, and various professionals (our personal community villages) who go above and beyond every day to make our lives possible...  and to all the people of conscious who listen, who care, who try and try again - and who never, ever give up because you know what is right and just and because it's just not in your soul's design to believe that one life is worth less than another... I'd like to take this opportunity to say Thank You!

Oh, I mentioned 63 counties; here they are... Clicking on the County links below will take you to the corresponding State representatives page on the North Carolina General Assembly's website.

1. Alamance County 
2. Beaufort County 
3. Bertie County  
4. Brunswick County 
5. Buncombe County 
6. Burke County 
7. Cabarrus County 
8. Caldwell County  
9. Catawba County 
10. Cherokee County 
11. Cleveland County 
12. Cumberland County 
13. Dare County 
14. Davidson County  
15. Duplin County 
16. Durham County  
17. Edgecombe County 
18. Forsyth County  
19. Franklin County  
20. Gaston County 
21. Granville County  
22. Guilford County  
23. Halifax County  
24. Harnett County 
25. Haywood County  
26. Henderson County  
27. Hertford County  
28. Hoke County  
29. Iredell County  
30. Jackson County  
31. Johnston County  
32. Jones County  
33. Lee County  
34. Lenoir County  
35. Lincoln County  
36. Macon County 
37. McDowell County  
38. Mecklenburg County 
39. Monroe County *voter representation falls under Union County
40. Moore County  
41. New Hanover County  
42. Onslow County  
43. Orange County 
44. Pasquotank County  
45. Pender County  
46. Pitt County  
47. Polk County  
48. Randolph County  
49. Robeson County  
50. Rockingham County  
51. Rutherford County  
52. Sampson County  
53. Stanly County  
54. Stokes County  
55. Transylvania County  
56. Union County  
57. Wake County 
58. Watauga County  
59. Wayne County 
60. Wilkes County  
61. Wilson County  
62. Union County  
63. Yancey County  

To find out who your voting representatives are, visit the NC General Assembly search page.

For more on who's involved and how to advocate, see Speak Up!

Appeals & Due Process (or Lack There Of)

I try very hard not to post a great deal of personal commentary. Though today I just couldn't help myself...

The North Carolina Department of Health and Human Services reached a settlement agreement with the US Department of Justice yesterday (8/23) regarding the State's ADA and Olmstead violations surrounding the improper placement and warehousing of mentally ill and developmentally disabled adults in adult care / nursing homes across the state. [ read more... ]

It is a victory. --However big or small it may seem is moot; it is nonetheless a victory in the recognition of a tremendous need and an acknowledgement of individuals deserving of a quality life and community interaction. Definitely a step in the right direction and I commend everyone involved for their diligence and efforts toward a just resolution.

Not to rain on the parade, but...

What continues to be of concern however, is that while we scurry to "deinstitutionalize" one vulnerable population and invest in services and programs to assure these individuals are properly supported in community environments as they are entitled, we are failing to bolster all the many thousands of other special populations who are already living in integrated settings, be it at home with their families or in supported living, etc. -- the ones who are not institutionalized and don't want to be -- whose loved ones desperately want to keep them in their homes... And yet, it seems that the very supports that allow that to happen, that they also are entitled to, continue to be trimmed away.

It's the human shell game: while we move one population toward community stability, we are pushing much of the rest, slowly but surely, straight into crisis. 

Without proper supports and proper funding for those supports, the reality is that many families will be forced to make the hardest decision of our lives - surrendering our loved ones to the state either because we will have to quit our jobs to provide full time care or we just cannot physically nor mentally do it anymore because we're already hanging on by a bare thread or both (which puts us right back where we started from and begs to question: where will they go? Can't put 'em in nursing homes, that's how we got into this mess to begin with.)

I had an exchange today with a weary and frustrated fellow mom in the eastern part of NC who is about to embark upon the grueling appeals process fighting for proper services and supports for her adult DD children that her family depends upon for their very existence. 

Yes, I said existence - not just the quality of life, certainly not for convenience and most definitely NOT for financial gain; EXISTENCE.

Like filing an appeal because services for your DD child(ren) are being drastically decreased and you simply cannot make do with less because you already are.

Through this dialogue I realized that the critical issues surrounding Medicaid appeals for DD recipients and Due Process, or lack of, are still not understood even on a basic level and misinformation continues to circulate.

Unless something has changed since June 2012 when I sent out and posted my Open Letter and Outline of Critical Medicaid Waiver Issues (with supporting documents), there remains NO FAILSAFE CONSTITUTIONALLY PROTECTED DUE PROCESS APPEALS PROCEDURE for Medicaid Waiver recipients and families! 

If something has changed, someone please let me know; I will be thrilled to update.

Otherwise, currently this is the way it works - or doesn't, as the case may be (from the outline):

What do we know about the Due Process / appeal procedures under the new 1915(b)(c) Medicaid Innovations managed care plan?

• The current appeals process reflects a consumer appeals process to a unilateral hierarchy with no third-party authority to fairly referee.
• As outlined in the PBH brochure and 2012 Provider Manual (pgs. 62-67) is as follows:
• If consumer caregiver has recipient service hours and / or benefits reduced, suspended or terminated,
• consumer caregiver will receive a letter 10 days prior to changes via US Certified Mail a letter, outlining instructions to request a ‘Reconsideration Review’ through PBH (or respective LME/MCO)’s ‘Reconsideration Review Process’ within 30 days of notification.
• If Reconsideration Review, does not yield a response in favor of consumer, consumer caregiver can appeal to both DHHS and the Office of Administrative Hearings (OAH) by filing a request for a State fair hearing within 30 days.
• Once appeal is processed, consumer caregiver may participate in an informal attempt to resolve the conflict through the Mediation Network of North Carolina;
• if the conflict cannot be resolved in mediation or if consumer declines mediation, the matter will be set for hearing before an Administrative Law Judge (ALJ) at the OAH.
• The ALJ will hear the matter and evidence and make a recommendation regarding the consumer’s matter and forward the decision to DMA,
• where DMA will review and make a final decision.
• What’s the point? More time and State financial resources wasted.
• The only recourse following a final decision by DMA is for the consumer to retain counsel and file suit in Superior Court - an extraordinary expense of tens of thousands of dollars that the vast majority of consumer families, including mine, could not afford.
• It should be noted that under the new PBH model, service eligibility for DD Medicaid Waiver recipients is determined by the Supports Intensity Scale (SIS) which arguably provides a more detailed client pictorial, however, the formula specifics which equates a recipient’s level of need by the State’s representative LME is deemed “proprietary information’:
• LME representatives are required to sign and enter into a “Non-Disclosure Agreement” with PBH to protect the SIS methodology.
• This non-disclosure further prevents a fair an adequate appeals process for consumers as how can one effectively challenge information which is withheld from them?
• Proprietary information as such held by an agent of the State providing public services to citizens on behalf of the State - services which are funded by Federal and State monies is, in fact, a conflict of interest.
• This is NOT transparency and only perpetuates mistrust.
• Also noteworthy: PBH recently had a federal lawsuit against acting NC DHHS Secretary Delia and Mann [5:12-CV-46] suing to not only remove final decision-making authority from the State government entity who is to oversee and govern the managed care operation and all LME’s, but to seemingly assure totalitarian authority.
• It is my understanding that this case has since been withdrawn.

OAH, ALJs and the Regulator Reform Act of 2011.

• NC SL 2011-398, commonly referred to as the Regulatory Reform Act, became State Law July 25, 2011, granting final authoritative ruling to OAH / ALJs over Medicaid cases, effective January 1, 2012 and applies to cases contested after that date.
• SECTION 32. G.S. 108A-70.9A(f) reads as rewritten: "(f) Final Decision. – After a hearing before an administrative law judge, the judge shall return the decision to the Department in accordance with G.S. 150B-37. The Department shall promptly notify the recipient of the final decision and of the right to judicial review of the decision pursuant to Article 4 of Chapter 150B of the General Statutes."
• SECTION 33. G.S. 108A-70.9B(g) reads as rewritten: "(g) Decision. – The administrative law judge assigned to a contested Medicaid case shall hear and decide the case without unnecessary delay. The judge shall prepare a written decision and send it to the parties in accordance with G.S. 150B-37."
• Despite the January 1, 2012 effective date for OAH final authority over recipient disputes in Medicaid matters, federally-funded Medicaid Waiver programs by design have a “single agency rule” which dictates that a single state agency makes final decisions in Medicaid issues which is somewhat conflicting given the design of the new statewide managed care waiver, therefore Centers for Medicare and Medicaid Services (CMS) must grant an exception waiver to the State of NC to permit alternate authority. Currently, NC governing officials and other interested stakeholders are working toward mutually agreeable waiver submission terms, though to date, an agreement has not be solidified.
• Thus there remains NO appropriate fail-safe due process for recipients and families save the unrealistic and unfeasible hardship of unnecessary legal expenses and lengthy court battles.

So essentially, if you disagree with an LME's decision regarding Medicaid services / supports, you pretty much are appealing to the person who instructed the decision to be made in the first place. If that doesn't work out, you can opt to undergo mediation and have a hearing before an ALJ who will then advise DMA of their opinion, but ultimately DMA still has final say.

The confusion seems to come from in between the State Law and the federal hang-up with CMS. 

Yes, NC State Law 2011-398 does in fact grant OAH final decision making authority BUT because of the federal "single agency rule," CMS must have a specific waiver from the State of NC in order for the federal government to allow another governing entity (e.g. OAH) to make decisions which affect federal monies. 

If North Carolina officials cannot agree on the waiver language for exception and this exception waiver is not submitted and approved by CMS before the final implementation of the statewide 1915(b)(c) managed care waiver, the period for appeals will have been exhausted and we may all be stuck with whatever decisions are made for us.

If you are in an appeals process, keep your representatives and advocacy groups informed - and as always, feel free to forward to me anything you wish to share.

*Update : More on Appeals and Due Process (feedback on this post) from Disability Rights NC.

What's New in June?

June 2012 events and updates.

• Parent Legislative Correspondence: SB 191 v 4: LME Governance, 6/28.
• Family Perspective: DMA 8M Clinical Coverage Policy proposal, Public Comment 361.
• Guardianship Issue and NCGA Senate Bill 191, 6/27.
• Message from The Arc of NC, 6/27.
• Provider Perspective: DMA 8M Clinical Coverage Policy proposal, Public Comment 292.
• Family Perspective: DMA 8M Clinical Coverage Policy proposal, Public Comment 220.
• Family Perspective: DMA 8M Clinical Coverage Policy proposal, Public Comment 293.
• In case you're wondering who I am...
• Mecklenburg County area Waiver Extensions. 
• Parent Correspondence and news articles questioning ECBH money management, 6/25.
• Parent Legislative Correspondence re: "Oversight of Quality of Care in Medicaid Home and Community Based Services Waiver Programs.", US HHS, CMS, & PBH, 6/25.
• Family Perspective: DMA 8M Clinical Coverage Policy Proposal, Public Comment 257.
• Family Perspective: DMA 8M Clinical Coverage Policy proposal, Public Comment 323.
• Opened the master Google Docs Repository re all things HB916 / Medicaid Waiver related for public viewing and download, 6/24
• Google Docs link posted on Documents page.
• Public Perspective: DMA 8M Clinical Coverage Policy proposal, Public Comment 227.
• Parent Perspective: DMA 8M Clinical Coverage Policy proposal, Public Comment 257.
• Parent Perspective: DMA 8M Clinical Coverage Policy proposal, Public Comment 266.
• Parent Perspective: DMA 8M Clinical Coverage Policy proposal, Public Comment 289.
• Parent Perspective: My Comments to the DHHS Waiver Advisory Council on 6/20.
• DRNC Press Release: Move to Intervene in ACH matter v. NC DHHS/DMA from 6/19.
• DHHS Waiver Advisory Committee Meeting Agenda for 6/20.
• NC DHHS Press Release re: Medicaid Leadership Reorganization, 6/19.
• Smokey Mountain Center's 6/13 NC Innovations Services Presentation and info.
• Associated Press article: "NC Medicaid director is out of a job," from 6/19.
• Winston Salem Journal article, "Changes to bill would give more power to groups overseeing mental health services" from 6/18.
• N&O article, "Costs soar for updating NC's Medicaid computer system" or Thing$ that Make U$ go Hmmm, from 6/17.
• Parent Legislative Correspondence: re PBH LME staff salaries & expenses, 6/18.
• Parent Correspondence: PBH Inquiry regarding executive salaries, 6/18.
• Blog Stats & Audience Following - Medicaid Waiver Interest for inquiring minds...
• No2NCHB916.blogspot.com StatCounter now Public
• added a Blog Stats quick link on the left.
• N&O article: "Judge halts effort to assign adult care homes special status" from 6/15.
• N&O article: "Medicaid budget to come up $75M short" from 6/15.
• Parent Legislative Correspondence: A Blast from the Past - 2007 Issues same as today in parent email archives, 6/14
• Carolina Journal Online article, "Medicaid Reforms May Leave Developmentally Disabled Out in the Cold; Unintended consequence of 2011 law to improve treatment of mentally ill" by Barry Smith from 6/11 as well as personal comments.
• Parent Perspective: N&O article "NC lawmakers direct another mental health overhaul" and Personal Comments, 6/13.
• Sign The Arc of NC's Online Petition!
• http://www.change.org/petitions/nc-leadership-change-house-bill-916
• Parent Perspective: Legislative Correspondence: An Open Letter & Outline of Critical NC Medicaid Waiver Issues for DD Citizens, 6/11.
• Parent Perspective: Legislative Correspondence to Representative Tim Moffitt from 5/31.
• Parent Perspective: Legislative Correspondence to Senator Tommy Tucker from 5/30.
• Parent Perspective: Legislative Correspondence to Representative Bill Current from 5/30.
• Attended the NC Behavioral Health and I/DD System Leadership Congress at UNC Chapel Hill with the Jordan Institute for Families, 6/8.
• Email from CMS re: Comprehensive and Supports Waivers, 6/6.
• NCGA 6/12 HHS Committee Meeting Notification & New Bills.
• added to Google Events Calendar
• CMS Denies CAP I/DD Waiver set to begin 7/1; Current Waiver Extension to be Requested, 6/5.
• Parent Perspective & Legislative Correspondence from Parent Mary Short re: 8M Clinical Coverage Policy proposals & Public Comment to DMA, 6/4.
• Public & Parent Perspectives: More on DMA's 2011 Clinical Coverage Policy proposals, the Public Comments received, & a quick rundown of the first proposal by parent, Mary K. Short.
• Reminder: Alliance LME Town Hall Meeting in Durham tonight! 6/4
• HHS Committee Meeting 6/5 and Bill Sponsor Notification.
• added to Google Events Calendar

[ What's New Main ]

AP Article: DMA Director Gray relieved of duties

NC Medicaid director is out of a job
The Associated Press
Posted: Tuesday, Jun. 19, 2012

RALEIGH, N.C. North Carolina's state Medicaid director is out of a job days after it became public that the government health insurance program faces a larger shortfall than previously expected.

State Department of Health and Human Services acting Secretary Al Delia announced Tuesday a shake-up in the agency's leadership that means Dr. Craigan Gray will no longer manage the Division of Medical Assistance. Gray had been on the job since 2009.

Department Chief Deputy Secretary Michael Watson will succeed Gray. Assistant secretary for mental health Beth Melcher will replace Watson.

Delia said late last week that an increase in provider claims would increase the Medicaid shortfall by $75 million.

A department spokeswoman said Gray was not replaced because of the shortfall but because Delia wanted someone with a different perspective.

Read more here:
http://www.charlotteobserver.com/2012/06/19/3328482/nc-medicaid-director-is-out-of.html

Legislative Correspondence to Rep. Bill Current

Wed, May 30, 2012 at 3:51 PM

From: Crystal J. De la Cruz  

To: Representative "Dr. William A. Current, Sr." 

Dear Dr. Current,

My sincere apologies for the delay in following up after our May 15th visit. It was a great pleasure meeting you and getting to know a bit about you as a person; I'm so glad the time afforded us a chance to chit-chat. Both [name stricken] and I were moved by your deeply-rooted integrity and moral compass. I dare say the world could use more people like you Dr. Current and your family is very lucky to have you. 

I greatly appreciate your time and attention in meeting with [name stricken] and I regarding Medicaid Waiver concerns for the DD populations, their families and the wonderful providers who have kept us all afloat throughout this rocky journey. 

No, it's not an easy life raising a child with profound special needs - in fact, unimaginable to most, but I can tell you one thing with the utmost certainty: at the end of the day, it's our special folks who keep it real and truly put life in perspective. That is why I do what I do because I am the mother Isabel needs me to be. I firmly believe special people were not born to be tested, rather to serve as litmus to the rest of us. 

Several members have expressed that they haven't heard from many parents. I keep pointing out that it is not an easy feat for many of these folks to pack up their kids with all their meds, supplies, sensory items, and equipment and travel hours away for a 30 minute - an hour meeting and well, most don't have the time nor vacation time because they use it all going to appointments with doctors and specialists. Most of us do the very best we can with what we got and sometimes there's no extra left over. And sometimes when we do let the laundry or dishes go or forgo a shower to take the time to sit down and write a letter, send an email - pleading for help, it falls on deaf ears.

I am polishing up additional materials for you that I hope to send later today regarding our prior visit and conversation, though meanwhile I wanted to share with you the attached documents forwarded to me by fellow parent Mary K. Short who finally received them yesterday from Brad Dean at the DHHS Office of Public Affairs. These are the Public Comment response records from 2011 regarding the 8M CAP I/DD Clinical Policy proposals posted from 5/12 thru 6/26 and from 7/28 thru 8/11 -- a total of 540 comments; 618 pages. Pretty interesting reading. And this is what's missing.

Comments were made from across North Carolina by many parents and caregivers sharing heartfelt details of their lives as well as professionals, providers, and advocates in the DD field who know well the devastating impact such changes and service cuts would have not only on the recipients and families they serve and care for, but on their small businesses, their livelihood and the lives of staff they employ as well.

My sincerest hope that our elected officials - our Governor and members of the North Carolina Senate and House of Representatives - aspiring candidates, policy-makers, Health and Human Services administrators, LME's, MCO's, and other stakeholders and powers that be take the time now to hear that voice as our lives are in your hands... not merely the quality of our lives but rather our ability to live.

I know I'm asking a lot of you to sit down with a book like this but I also know you understand the importance of the messages inside. Thank you again for your time and attention and thank you in in advance for your considerations.

Kind regards,

-- 

Crystal J. De la Cruz - Hopper

Mother, Advocate & Concerned Citizen

When we allow the value of human life to be determined by capital gain, when we sacrifice the well-being of the most innocent among us to compensate our own shortcomings, and when we judge the worth of our most fragile, not by their character nor intention, but rather their abilities – We Are in Crisis.

http://no2nchb916.blogspot.com/

"The moral test of government is how it treats those who are in the dawn of life . . . the children; those who are in the twilight of life . . . the elderly; and those who are in the shadow of life . . . the sick . . . the needy . . . and the disabled." 

--Hubert H. Humphrey

2 attachments

20110512-0626 NC-DHHS-DMA Public Comments 8M CAPIDD.doc [598K]

20110728-0811 NC-DHHS-DMA Public Comments 8M CAPIDD.doc [2786K]

from CMS re Comprehensive & Supports Waivers

From: Connie.Martin@cms.hhs.gov
To: MaryKShort@aol.com
Sent: 6/6/2012 10:00:59 A.M. Eastern Daylight Time
Subj: RE: Follow-Up re CAP-IDD waiver

Dear Ms. Short,

The CAP-IDD waiver (a.k.a., NC 0662, Comprehensive waiver) is not yet approved. We continue to work with the State toward getting the waiver approved.

We are also working with the State to get the NC 0663, Supports waiver for MR/IDD individuals approved. NC 0663 has the same extension date as the Comprehensive waiver. As you probably already know, the Supports waiver provides services for those individuals who needs are less severe than the individuals in the Comprehensive waiver.

Thank you,
Connie

From: MaryKShort@aol.com [mailto:MaryKShort@aol.com]
Sent: Tuesday, June 05, 2012 6:39 PM
To: Martin, Connie L. (CMS/SC)
Subject: Follow-Up re CAP-IDD waiver

Hi Connie. Here it is the beginning of June and we are all wondering (AGAIN - not your fault that our DMA does not let anyone know anything) if the CAP-IDD waiver is approved? We all know there is an extension to 06.28.2012. Thank you.

Mary K. Short
828-632-5888 or 704-451-4144 (cell)

NCGA 6/12 HHS Committee Meet & New Bills

NORTH CAROLINA HOUSE OF REPRESENTATIVES

COMMITTEE MEETING NOTICE

AND

BILL SPONSOR NOTIFICATION

2011-2012 SESSION

You are hereby notified that the Committee on Health and Human Services will meet as follows:

DAY & DATE: Tuesday, June 12, 2012
TIME: 10 :00 am
LOCATION: 544 LOB
COMMENTS: The following bills will be considered:

BILL NO. HB 975
SHORT TITLE: Promote Local/Healthy Food.
SPONSOR: Representative LaRoque, Representative Sanderson, Representative Insko 

BILL NO. HB 1098
SHORT TITLE: Continue the Sustainable Local Food Advisory.
SPONSOR: Representative Sanderson, Representative LaRoque 

BILL NO. SB 433
SHORT TITLE: Local Human Services Administration.
SPONSOR: Senator Hartsell 

BILL NO. SB 525
SHORT TITLE: Streamline Oversight/DHHS Service Providers.
SPONSOR: Senator Tucker, Senator Hartsell

Respectfully,
Representative Current, Chair
Representative Dollar, Chair
Representative Hollo, Chair

I hereby certify this notice was filed by the committee assistant at the following offices at 1 PM o’clock on June 07, 2011.

Principal Clerk
Reading Clerk – House Chamber

Wendy Miller (Committee Assistant)

CMS Denies 7/1 CAP-IDD Waiver

From: tames@durhamcountync.gov

Sent: Tuesday, June 05, 2012 2:10 PM

Subject: June 21st CAP Waiver training

I just learned that the CAP I/DD Waiver that was to go into effect July 1st has not been approved by CMS. Therefore, another extension of the current waiver will be requested.

Due to this development, the CAP I/DD Waiver training scheduled during our June 21st TCM agency supervisor meeting has been cancelled until further notice.

Terry Ames

Intellectual and Development Disabilities Program Specialist

The Durham Center

919.560.7511-office 919.560.7250-fax

tames@durhamcountync.gov

www.durhamcenter.org

Parent Perspective & Legislative Correspondence

Mary K. Short is a strong and active advocate and the parent caregiver of an adult DD recipient with profound needs. She fights tirelessly for the rights of her daughter, Katie and other special families, as well as a great deal of time keeping folks informed! Below is her mail to her parent list (in blue) which includes her 6/4 legislative correspondence regarding the 8M Clinical Coverage Policy proposals and Public Comments to DMA. Posted with Mary's permission.

Mary and her daughter live in NC House District 88 and Senate District 42. Her daughter is being served by Smoky Mountain LME.

Parent Perspectives 

and Legislative Correspondence

From:  Mary K. Short  June 5, 2012
Hello all. As I have been trying to stop the further implementation of the NC Innovations waiver, one of the things I have repeatedly told the Members of the NC General Assembly (NCGA) is that the Department and Divisions DO NOT LISTEN TO FAMILIES. One of the things that had been bothering me is the fact that "Proposed Clinical Policy 8M CAP-IDD" was never posted to the DMA web site as approved. You should recall that it was posted for public comments twice, for a 45-Day period (May 12, 2011 - June 26, 2011) and then again for a 15-Day period (July 28, 2011 - August 11, 2011). The 15-Day comment period was when Home Supports was eliminated! I submitted a Freedom Of Information Act request (FOIA) and after some delay by the Department and Divisions, I did actually receive the documents! They sent me Word file documents of ALL the public comment they received. The links below are to those documents. PLEASE BE AWARE THAT I HAVE NOT REMOVED ANY INFORMATION FROM THE PUBLIC COMMENT DOCUMENTS. They contain email addresses, addresses, phone numbers, WHATEVER was submitted is what was released. I have not edited the information in any way.

https://www.sugarsync.com/pf/D6195569_4698706_718588 (Part 1: 539 pages; 439 comments; 15 day comment period.)

https://www.sugarsync.com/pf/D6195569_4698706_718581 (Part 2: 79 pages; 101 comments; 45 day comment period.)

They are tremendously moving to read. I want to thank every single family who submitted comments. I want to add that MOST of the comments are NOT from people who are directly on my email list. I know some of you forward my emails, and so, I want to thank you for doing that. I don't care if the comments are from my email group or members of The Arc or UCP or Case Management providers or service providers, whoever, I am just thankful for the families who did comment. Except for two that I remember, they were in COMPLETE AND TOTAL OPPOSITION to the elimination of Home Supports, the implementation of a 40-hour policy, and opposed denying the use of Respite on the same day as Home Supports or Residential Supports.

After having all of it printed and READING EVERY SINGLE PAGE, I sent the following email:

From: MaryKShort@aol.com

To: Governor Beverly Perdue <governor.office@nc.gov>, 

Senate President Pro Tempore Phil Berger <Phil.Berger@ncleg.net>, 

House Speaker Thom Tillis <Thom.Tillis@ncleg.net>, 

Senator Louis Pate <louis.pate@ncleg.net>, 

Representative Justin P. Burr <justin.burr@ncleg.net>, 

Representative Nelson Dollar <nelson.dollar@ncleg.net>, 

Representative Martha Alexander <martha.alexander@ncleg.net>, 

Representative William Brisson <william.brisson@ncleg.net>, 

Representative William A. Current, Sr. <bill.current@ncleg.net>, 

Representative Mark W. Hollo <mark.hollo@ncleg.net>, 

Representative Pat B. Hurley <pat.hurley@ncleg.net>, 

Representative Bert Jones <bert.jones@ncleg.net>, 

Representative Marian McLawhorn <marian.mclawhorn@ncleg.net>, 

Representative Tom Murry <tom.murry@ncleg.net>,

Representative Fred F. Steen, II <fred.steen@ncleg.net, 

Senator Austin Allran <austin.allran@ncleg.net>, 

Senator Doug Berger <doug.berger@ncleg.net>, 

Senator Stan Bingham <stan.bingham@ncleg.net>, 

Senator Harris Blake <harris.blake@ncleg.net>, 

Senator Jim Davis <jim.davis@ncleg.net>, 

Senator Fletcher Hartsell <fletcher.hartsell@ncleg.net>, 

Senator Eric Mansfield <eric.mansfield@ncleg.net>, 

Senator Martin L. Nesbitt, Jr. <martin.nesbitt@ncleg.net>, 

Senator William R. Purcell <william.purcell@ncleg.net>,

Senator Tommy Tucker <tommy.tucker@ncleg.net>, 

Senator Andrew C. Brock <andrew.brock@ncleg.net>, 

Senator Ralph Hise <ralph.hise@ncleg.net>, 

Joint Caucus Leader Marilyn Avila <marilyn.avila@ncleg.net>, 

Representative Rayne Brown <rayne.brown@ncleg.net>, 

Representative Tricia A. Cotham <tricia.cotham@ncleg.net>, 

Representative Beverly M. Earle <beverly.earle@ncleg.net>, 

Representative Shirley B. Randleman <shirley.randleman@ncleg.net>, 

Representative Mitchell S. Setzer <mitchell.setzer@ncleg.net>, 

Representative Tim Moffitt <tim.moffitt@ncleg.net>

CC: MaryKShort@aol.com

Sent: 6/4/2012 7:34:52 A.M. Eastern Daylight Time

Subj: Public Comments to 8M Clinical Policy - links provided

Dear Gov. Perdue, Sen. Berger, Speaker Tillis, and Members of the NCGA:

On 04072012 I sent a Public Records request to DHHS. I have no idea why there was a problem with getting it to the right person. That FOIA (Freedom Of Information Act) request was for ALL of the public comments that were submitted to DHHS/DMA for Proposed Clinical Policy 8M CAP-IDD. There were two comment periods. May 12 - June 26, 2011 (45 days) and July 28, 2011 - August 11, 2011 (15 days.)

In a phone call with Susan E. Johnson at DMA on 05082012, she told me she had compiled and sent that 8M public comment information to DHHS. (Additionally, on 05082012, I emailed her requesting the "best practice documentation" for the family as provider 40 hour policy. However, as of today, I still have NOT received the best practice documentation. I followed up with her on 05172012 and her reply on 05182012 was that she had asked DHHS to assist her.)

Brad Deen, DHHS, spoke with me at the MCAC (Medical Care Advisory Comm.) Meeting on 05182012 and told me he had sent the documents to a different Mary Short email address. I was confused by that since I had made the request in an email to begin with. I gave him the correct information and he said he would send it. When I had not received the information by 05292012, I tried email again. Two emails and a phone call later, I received the documents on 05292012. They are in Word. I have provided links to the documents rather than attaching them to this email.

https://www.sugarsync.com/pf/D6195569_4698706_718588 (Part 1: 539 pages; 439 comments; 15 day comment period.)

https://www.sugarsync.com/pf/D6195569_4698706_718581 (Part 2: 79 pages; 101 comments; 45 day comment period.)

When we were in Raleigh on 05302012 and 05312012, I had the documents on a thumb drive with me and I told as many legislators as I could about what was in the documents I had barely had a chance to read. Sen. Daniels' LA, Andy, downloaded the documents. I have sent them as email attachments to some other people, too. Additionally, I have sent them to the HHS/OCR attorney in Atlanta who has been assigned my (our) complaint because I specifically complained about 8M and that DHHS/DMA/DMH not listening to the comments.

On Friday, 06012012, I had both documents printed out. Over the weekend, 06022012-06032012, I did read every single page. There were two comments in favor of the proposed changes, both from LME/MCO's. Mothers, fathers, brothers, sisters, aunts, uncles, cousins, grandparents, or any other family relation you can imagine, all wrote to beg that DMA not change the CAP-IDD(MR/DD) waiver by eliminating Home Supports or limiting families to 40 hours a week. These are very, very compelling comments. Agencies, such as The Arc or UCP or ASNC (Autism), all wrote to oppose the elimination of Home Supports or to oppose the 40 hour limit. And yet, DMA did just that. You must be wondering, just as I am, why it is that if there are 1,091 +/- parents performing Home Supports in all of NC and 500 comments were received in opposition to the elimination of Home Supports or the 40 hour policy, then why would DMA do it? I sincerely believe it is because they are simply mean-spirited. There is no logical reason to believe otherwise.

I have spent time and effort in an attempt to convince you that there is a problem at DHHS/DMA/DMHDDSAS. I don't know what it is you need to have in your hands in order to believe me and in order to take any action to stop the further expansion of the 1915(b)(c) waivers and more specifically, the 1915(c) NC Innovations waiver. Please. The PBH pilot of the Innovations waiver INCLUDED its own HOME SUPPORTS service definition. It was just in July of 2011 that the NC Innovations waiver eliminated Home Supports and implemented a 40 hour policy. The NC Innovations waiver that is being expanded is NOT the Innovations waiver that was piloted by PBH all those years.

The fact the CMS has approved any State Plan or State Plan Amendment or Waiver is NOT proof that what DHHS/DMA/DMHDDSAS has done is legal. You all are acutely aware of the DOJ findings with regard to ACH/IMD and Personal Care Services. The fact that there is a pending lawsuit (K.C. v NCDHHS, PBH, et al.) brought against PBH after the changes to the piloted Innovations waiver is also proof of some level of disregard of the PEOPLE impacted by the Innovations waiver.

The financing of this waiver through a capitation formula which results in a month to month variable check to the LME/MCO's rather than an annual appropriation by the NCGA which always allowed for growth (moving people off of the wait list and into direct services) is flawed or a sham, or both!

The fact the MONEY has been spent by LME/MCO's on this expansion is not an argument to continue the expansion. Clearly, DHHS/DMA/DMHDDSAS has wasted millions of dollars in the past on policies or programs that have failed. Those live human beings in the IDD community are simply the least able to recover from another DHHS/DMA/DMHDDSAS "failed" policy.

Please stop the further expansion of the NC Innovations waiver. Thank you all, again.

Mary K. Short and Katie

828-632-5888 or 704-451-4144 (cell)

I have not given up in any way. Because the public comments are public documents, you can forward the links to anyone you choose.

Finally, I want to address the issue of "our" information being public. I am sorry if any of you did not want your information released, but the DMA web site is very clear that the information that is given as a public comment can, in fact, be released as a public document. I am hopeful that all of us feel it is more URGENT and IMPORTANT to speak out against these changes, than to be silenced by the threat that our information may be made public. Of course, you can always sign up for a gmail or yahoo email account rather than using your "real" email account to send "public comment" from!

Mary K. Short

828-632-5888 or 704-451-4144 (cell)

Public & Parent Perspectives: Did You Hear Our Voice?

In case you missed the posting of DMA's Public Comments on the 8M Clinical Coverage Policy proposals in May and July of 2011, I'm posting again as I recently updated the post with additional files - namely the 2 different proposals which were posted for comment, a side-by-side comparison of the two proposals, and the 2010 8M Clinical Coverage Policy prior to the changes.

Here are the documents again:

ORIGINAL PROPOSED CLINICAL POLICIES for CAP-IDD:

• DMA 8M Clinical Coverage Policy for CAP-IDD proposal posted for 45 day Public Comment period (05/12 thru 06/26).
• DMA 8M Clinical Coverage Policy for CAP-IDD proposal posted for 15 day Public Comment period (07/28 thru 08/11).

NOTE: The 15-day posted proposal drastically differs from the 45-day posted proposal, with a total of 14 pages deleted from the second proposal posted.

• Side-by-side document comparison of DMA's two 8M proposals.
• DMA 8M Clinical Coverage Policy for CAP-MR/DD from July 2010.

PUBLIC COMMENTS on CAP-IDD CHANGES:

• DMA Clinical Coverage Policy for CAP-IDD proposal Public Comments from May 12, 2011 thru June 26, 2011 (101 comments; 79 pages).
• DMA Clinical Coverage Policy for CAP-IDD proposal Public Comments from July 28, 2011 thru August 11, 2011 (439 comments; 539 pages).

Comments were made from across North Carolina by many parents and caregivers sharing heartfelt details of their lives as well as professionals, providers, and advocates in the DD field who know well the devastating impact such changes and service cuts would have not only on the recipients and families they serve and care for, but on their small businesses, their livelihood and the lives of staff they employ as well.

It is our sincerest hope that our elected officials - our Governor and members of the North Carolina Senate and House of Representatives - aspiring candidates, policy-makers, Health and Human Services administrators, LME's, MCO's, and other stakeholders and powers that be take the time now to hear that voice as our lives are in your hands... not merely the quality of our lives but rather our ability to live.

Here's a synopsis / overview of the initial 8M Clinical Coverage Policy proposal posted for comment from May 12 - June 26 from special parent, Mary K. Short (Mary's comment in blue, the rest are quotes from the 8M). --Remember, the second proposal is less 14 pages.

There are a couple of things that caught my eye. The most important may be that they have proposed changing the respite policy so that you CANNOT use respite on a day you use Home Supports or are an AFL. I would hope you all contact your child's primary care physician and ask him/her to send in a comment to the DME web site in opposition of that proposal. Remember, the comments are reviewed by the PAG (Physician's Advisory Group) and I think your MD's comments are going to carry more weight than your comments. BUT you should send you comment, too! I have never understood where the "best practice" is that says respite cannot be regular and scheduled, so I certainly cannot understand where the "best practice" is that says the primary caregiver can't use four (4) hours of respite every Sunday so they can attend church services in order to pray for strength to continue fighting the battle against ridiculous proposed clinical policies!


The respite changes are throughout the document! However, in the list of Service Definitions, either Crisis Respite or Respite pretty much spells it out. Page 54 of the document or page 101 and then go to the "Service Limitation."


The next couple of things that caught my eye are outlined below. The first is this idea of "habilitative" and how it jumps in and out throughout the proposed clinical policy. The most disturbing loss of habilitation comes in the form of Residential Services to replace Residential Supports. The new Residential Services is NONHABILITATIVE and that would seem to signal the providers that they could now simply park an individual in front of a TV! I am sure it also signals a tremendous rate change coming to them. But somehow, AFL's, who are paid that service definition of Residential Services, is singled out as HABILITATIVE. Huh? And then that designation as HABILITATIVE for both AFL's and HOME SUPPORTS limits the individual to 129 hours of any combination of habilitative services (day supports, HCS, etc.), yet the Residential Services individual has a limit of 209 hours! That is a HUGE penalty for living in an AFL or in a family home ... or is it a HUGE incentive to move to a group home?

Bottom of page 2: ...

1.1.5 Habilitation Services
Habilitation services are those services designed to assist participants in acquiring, retaining, and improving the self-help, socialization and adaptive skills necessary to reside successfully in home- and community-based settings.

Bottom of page 10: ... this is eliminated:

Residential Supports is a habilitation service, with built-in Personal Care at a daily rate to meet the flexible daily needs of the individual. As a blended service, its range of hours for each NC-SNAP level of service (Level 1 through Level 4) includes both components—personal care and habilitation. This hour range
indicates the hours of direct contact service and support expected for each level of the service.

Top of page 11: ... and is replaced with this:

The service also provides assistance, support, supervision, and monitoring that supports individuals to participate in home or community activities. This service is not a habilitative service; however, the service shall be conducted in a manner that promotes and encourages independence

Page 12: Home Supports remains habilitative:

5.1.3 CAP-MR/DD CAP-I/DD Participants Receiving Home Supports 
Home Supports is provided only to adult participants who reside in their natural home with their parents (natural, adoptive or step parents) and other family members, where the parents (natural, adoptive or step parents) of the adult participant request to provide the Home Supports to the participant. Home Supports is a habilitation service, with built-in Personal Care at a daily rate to meet the flexible daily needs of the individual. As a blended service, its range of hours for each NC-SNAP level of service (Level 1 through Level 5) includes both components—personal care and habilitation. This hour range indicates the hours of direct contact services and support expected for each level of the service.

Page 14: The second paragraph says to focus on habilitation needs:

5.3.2 Person Centered Plan Reviews
At a minimum, the responsible professional (Targeted Case Manager) shall review the Person Centered Plan based upon the target date assigned to each goal, when the individual’s needs change, or when a service provider changes. For CAP-MR/DD CAP-I/DD participants, the Targeted Case Manager shall
review the Person Centered Plan every year prior to the individual’s birthday month.

The person-centered planning team shall focus on the habilitation needs of the
individual. Services that are habilitative in nature are not covered under the State
Plan except in an ICF-MR; however, they may be covered as a distinct waiver
service. In reviewing the Person Centered Plan, the Targeted Case Manager shall
include a review of the individual’s progress toward meeting goals identified on
the existing plan and document adjustments made as necessary.

Page 37: An AFL setting is habilitative:

Alternative Family Living
For the purposes of the CAP-MR/DD CAP-I/DD waiver, an Alternative Family Living (AFL) home or adult foster home is considered an out-of-home setting for a person who chooses this setting. The participant receives 24-hour care and lives in a private home environment with a family who are paid to provide services to address the care and habilitation needs of the participant. The family will continue to reside in this home if they choose to no longer provide supports and the participant moves from their home. The LME and targeted case manager are responsible for monitoring the health and safety of the participant. CAP-MR/DD CAP-I/DD funds may not be used for room and board costs.

Page 64: (Day Supports AND Home & Community Supports service limitations both have this service limit sentence about habilitation hours and residential setting.)

Service Limitations:
The maximum combined habilitation services limit is 129 hours per month for all habilitative services with the exception of individuals receiving Residential Services who may receive up to 204 hours per month for all habilitative services.

Page 75: (Home Supports is habilitative.)

K. Home Supports
Service Definition and Required Components:
The intent of this service is to meet the habilitation and personal care needs of adult participants (18 years or older) who choose to live with and receive supports from their families and whose families wish to provide services to the participant in their family homes. Home Supports is designed to provide flexibility and reflect the natural flow of the participant’s day. ...

... This service is distinctive in that it includes habilitation and training activities, as well as care and assistance with activities of daily living when the participant is dependent on others to ensure health and safety. ...

Bottom of page 77: (Underline indicates STRIKE OUT.) Utilization Management (UM) for Home Supports eliminates habilitation:

f. This service requires identification of goal directed progress
g. Habilitation requires goal related process on the Person Centered Plan

Page 85: (NO STRIKE OUT ?!) UM for Long Term Vocational Supports or Specialized Consultative Services or Supported Employment keeps habilitation:

f. This service requires identification of goal directed progress
g. Habilitation requires goal related process on the Person Centered Plan

Page 93: (COMPLETE STRIKE OUT) Residential Supports eliminated.

Residential Support Services
Service Definition and Required Components:
Residential Support Services provides assistance with acquisition, retention, or improvement in skills related to activities of daily living, such as personal grooming and cleanliness, bed making and household chores, eating and the preparation of food, and the social and adaptive skills necessary to enable the individual to reside in a non-institutional setting. Habilitation, training and instruction, blended with elements of support, supervision and engaging participation, are combined to reflect the natural flow of training, practice of skills,
and other activities as they occur during the course of the person’s day. This service is distinctive in that it includes habilitation and training activities, as well as care and assistance with activities of daily living when the individual is dependent on others to ensure health and safety. ...


Page 97: Residential Services replaces Residential Supports and is now non-habilitative:

Q. Residential Services
Service Definition and Required Components
Residential Services provides personal care and supervision for individuals residing in out of home placements. These homes include licensed residential Group Homes and Alternative Family Living Homes (AFLs) and residential settings not requiring licensure such as one person Alternative Family Living Homes and One Person Group Homes. A one person group home is a home that is operated by a provider agency. In a One Person group home if the participant wishes to change to a different Residential Service provider, the individual is required to move to another location/residential setting.


Residential Services includes personal care and assistance with activities of daily living as appropriate for the support need of the individual. The service also provides assistance, support, supervision, and monitoring that supports individuals to participate in home or community activities. This service is not a habilitative service; however, the service should be conducted in a manner that promotes and encourages independence. ...

Page 100: Again, an AFL is habilitative:

Additional Guidance:
For the purposes of the CAP-I/DD waiver, an Alternative Family Living Home or Adult Foster Home for one person is provided as an out of home placement for a person who chooses this setting or whose family cannot provide care for that person. The individual receives 24-hour care from and lives in a private home with a family in a home environment where the services are for the care and/or habilitation of the individual. The home does not require a license because it serves only one adult with a developmental disability. The LME and targeted case manager jointly monitor the health and safety of the participant. ...