Ongoing problems with NC's managed care transition, and how to address them

From The Arc of North Carolina

Ongoing problems with NC's managed care transition, and how to address them

In mid-2011, the NC legislature passed a bill that would dramatically change the way the state of North Carolina provides services for people with developmental disabilities, mental illness, and substance abuse (MH/DD/SA) issues. The state would shift from a fee-for-service system to a managed care system.

The Arc originally opposed the move to a managed care system and still has significant reservations about the design. However, the political reality is that managed care is here to stay, and The Arc is committed to ensuring that NC's managed care system effectively meets the needs of people with disabilities.

A year and a half after the initial move towards managed care, we are feeling the impact of the plan’s short-sighted design and hasty implementation. Across the state, many of the entities responsible for implementing the shift to managed care (generally referred to as LME/MCOs) are struggling to make the managed care transition and are behind schedule. The effects of these transition problems can be felt throughout North Carolina.

In Mecklenburg County, the state first found that MeckLINK, the LME/MCO responsible for MH/DD/SA services in the area, had not achieved the necessary milestones to switch to a managed care model by its February 1st deadline. The state then re-assigned the responsibility to implement the new managed care system in Mecklenburg to a LME/MCO already operating under the managed care system, Cardinal Innovations Behavioral Healthcare. This decision meant that millions of dollars of public money MeckLINK spent preparing for the new managed care system would be wasted, and Mecklenburg County would adopt the new managed care system several months later than planned.

On January 23, DHHS, now under the leadership of Governor McCrory’s administration, gave MeckLINK a new target date of March 1st, providing it meets its “readiness benchmarks.” This change occurred just eight days before Cardinal Innovations was to take over.

In the southeast corner of the state, Coastal Care, the LME/MCO responsible for MH/DD/SA services for 5 counties including New Hanover, will miss its deadline to convert to the new managed care system by February 1st. While this came to light recently and details are scarce, for whatever reason the LME/MCO is not prepared to switch to the managed care system on schedule, which will result in a significant loss in savings.

Large overruns and implementation controversies are nothing new to NC’s managed care transition. Starting in January 2011, Western Highlands Network, the LME/MCO that manages MH/DD/SA services in 8 counties in the western part of the state, ran a monthly deficit of over $500,000.

Not every LME/MCO has made headlines with its transition to managed care. Many have made the transition largely out of the limelight, but questions remain about their readiness and the effectiveness of current operations.

Obviously, there have been significant problems with North Carolina’s transition to a managed care system for MH/DD/SA services. Now is the time for state leaders to learn from these controversies and make reasoned decisions about the future of our system, and the people it serves.

The Arc believes problems with the state’s transition to managed care stem from an overzealous rush to find savings, rather than a thoughtful and deliberate approach to system design. The operationally arbitrary deadlines for management entities to convert to the managed care waiver are a key example. Converting to a managed care system is not easy- it is expensive and disruptive. We must be sure that LME/MCO’s are truly ready to begin before they turn the switch.

The struggles of LME/MCOs the state deemed ready to move forward to the new system, including Western Highlands Network, prove that the prior notion of what ‘ready’ means is insufficient and needs to be re-examined. Clearly, LME/MCOs must prepare business systems capable of dealing with the large volume of claims, payments, and calls they will receive. It is also important that they are prepared to implement any new services available under the managed care system, respond to people with disabilities and their families about their concerns, and have a well-trained provider network that understands the intricacies of the new system.

Our system’s focus should be on the needs of individuals it is meant to support and the providers working within the system, rather than dreams of short term savings. Getting it right the first time with a well-measured, steady approach will lead to efficiency, cost containment, and higher satisfaction among consumers, providers, and LME/MCOs.

The Arc believes we must adhere the following basic principles if we are to make this transition to Managed Care successful. 

Stability for individuals served and those who provide the services must be the highest transition priority. No LME/MCO should be allowed to shift to managed care if they are not ready. It should be clear that readiness means the ability to successfully support people with disabilities. 

Decisions about LME/MCO mergers and “assignments” need to be about competency and not about politics. 

Where competing goals exist, the state needs to be clear about which it values more. For example, ‘local public management and ‘administrative efficiencies’ are not always mutually exclusive, but in certain areas they may be. 

All interested parties, including The Arc, must be open to new ideas and approaches surrounding managed care. There is no dishonor in adjusting a plan to meet current circumstances. The needs of people with disabilities should dictate policy, not the established position or ego of any state agency, MCO/LME, private organization, or individual. A real partnership with stakeholders must be achieved if we are going to succeed.

Finding savings within state systems for people with disabilities is certainly laudable, but if the savings mean sacrificing the ability of the system to perform its mission, then they are counter-productive. As the saying goes, buy it right or buy it twice.

Comments

MCO's

We who are involved in all the changes sit back and watch and read all that is occuring. We hear that different MCO's get different PMPM amounts and do not understand why. We hear that LME's can not get it together in the outlined time frame. We watch and read about Western Highlands being half a million dollars in the red for months while the board did not realize it. We hear and wonder how MCO's like Western Highlands have the monies to hire agencies like the private group they hired at the cost of hundreds of thousands of dollars to tell them what they are doing wrong after this State hired Mercer to tell them that and still the Mercer organization is at Western Highlands looking at what they are or are not doing right over a year after they began operating while the private agency is there. Now we hear of Mercer going into other LME's to see if they are ready. Why? We watch Western Highlands fire their CEO and pay an agency thousands of dollars to locate a new CEO. We hear agencies not getting reimbursed in a timely manner over never ending changing requirements. We have watched as agency, therapists and psychiatrist have left Western Highlands and I am sure this is the same for other MCO's and wonder where this State is in thinking of the Best Interest of the individuals that they are to serve while spending monies on things that should have already been in place. What is wrong with this picture? Does anyone wonder why all these monies are being spent on requirements that were supposed to be in place instead of on the individuals that they are to serve. I have not heard of any direct care staff which are the back bone of all this getting anything extra for all their efforts. We are forgetting the reason all these MCO's were started, the individuals that they are Supposed to Serve.

Arc NC Action Alert!

There are three important federal matters that require your immediate advocacy!

Don't Go Over the Fiscal Cliff!

What's the Issue? If the deficit negotiations are not complete by January 2nd, the country faces steep automatic budget cuts ("sequestration") on everything from Defense to IDEA and Head Start, Vocational Rehabilitation, Section 811 housing among others. It would hurt all Americans, including those with intellectual and developmental disabilities. Click here to learn more...

What can I do? Send a letter to Senators and Representative telling them that sequestration is not an option. It's easy, just click below, enter your zip code, and our system will automatically generate a message that's ready to send. We encourage  you to personalize the pre-generated message.

Click Here to Send a Message to Your Senators and Representative!

Ratify the Convention on the Rights of Persons with Disabilities!

What's the Issue? The United Nations Convention on the Rights of Persons with Disabilities (CRPD) empowers individuals with disabilities across the globe to be independent and productive citizens while treated with respect and dignity by outlining rights of citizens and responsibilities of their home countries.   Based largely on US law, the CRPD would not change our laws or cost any money.  Instead, ratifying the CRPD would give the U.S. the opportunity to provide technical assistance and guidance to over 125 countries in a meaningful way. Click here to learn more...

The Senate may take up the CRPD as early as TODAY.  Senators Burr and Hagan need to hear from you now.

What Can I do? Sen Hagan has said she supports ratifying the CRPD, but Sen. Burr's position is unknown. Send a letter to Sen. Burr urging him to vote in favor of ratification of the CRPD. It's easy, just click below, enter your zip code, and our system will automatically generate a message that's ready to send. We encourage  you to personalize the pre-generated message.

Click Here to Send a Message to Sen. Richard Burr!

Stop H.R. 2032!

 What's the Issue? H.R. 2032 is a bill that would place restrictions on the ability of state Protection and Advocacy Agencies (such as Disability Rights NC) to bring class action lawsuits on behalf of individuals with disabilities in intermediate care facilities, effictively creating a seperate type of 'justice' for people with I/DD. This bill is opposed by The Arc, Disability Rights, The American Bar Association, and many more. It's primary supporter outside of Congress is a group called Voice of the Retarded. Click here to learn more...

What  Can I do? Contact Rep. Howard Coble (R-NC), a co-sponsor of the bill, and let him know that this bill is NOT in the best interest of people with intellectual and developmental disabilities. It's easy, just click below, enter your zip code, and our system will automatically generate a message that's ready to send. We encourage  you to personalize the pre-generated message.

Click Here to Send a Message to Rep. Coble!

Tillis Requests Special Session To Address PCS/Group Home Crisis

From The Arc of North Carolina

Tillis Requests Special Session To Address PCS/Group Home Crisis

Special Session first step to solve crisis before Holiday break   Speaker of the NC House Thom Tillis has formally requested that Governor Perdue convene a Special Session of the General Assembly in order to address the looming Personal Care Services (PCS) crisis that threatens the housing of thousands of people with disabilities living in group homes. The Arc of North Carolina is thrilled by this development and appreciates the Speaker's leadership on this issue and his continued dedication to North Carolinians with intellectual and developmental disabilities. The Arc will continue to keep you updated on the PCS/Group Home Crisis as it develops. Please check www.ArcNC.org for information as it happens. The Arc's advocacy staff is evaluating it's next steps in terms of advocacy. Look for an action alert next week. The letter from the Speaker's office is below. See a copy of the original here. --- Governor Perdue, As you know, the General Assembly appropriated $39.7 million in this year's budget to provide for temporary, short-term assistance to residents who would no longer be eligible to receive Medicaid State Plan Personal Care Services under the new eligibility criteria, effective January 1, 2013. The budget provision was drafted as a short-term measure to ensure the funds went to those affected residents who would be potentially discharged from their facility, but would not immediately have a safe community placement. This budget provision was intended to prevent the Department of Health & Human Services from using funds for administrative expenses, appeals, rent deposits, or other items, as requested by the Department during budget negotiations. The Blue Ribbon Commission was summarily tasked with developing long-term solutions to ensure Medicaid beneficiaries receive the services they need. The General Assembly has been working diligently over the last several weeks and months to determine solutions that would prevent the potential unintended closure of mental health and IDD group homes at the conclusion of this calendar year. It is now incumbent upon all of us to do what is necessary to solve this problem. In order to ensure that our state's most vulnerable citizens are protected and allowed to remain in their homes, it is my opinion that legislative action by the General Assembly is needed. Therefore, I respectfully request that you convene a Special Session of the General Assembly under the authority granted to you by Article Ill, Section 5(7) of the North Carolina Constitution. The North Carolina House of Representatives stands ready to take immediate action to resolve this impending problem. If you should decide to convene a Special Session, you have my word that no additional matters will be taken up by the House of Representatives. We will act quickly and decisively to protect the residents of mental health and IDD group homes, and the session will end when that action is concluded. I look forward to your prompt reply. Thank you for your time and attention concerning this very important matter. Sincerely, Thom Tillis   cc: Senator Phil Berger

It's Time to Make Your Voice Heard - Time to Vote!

From The Arc of North Carolina

It's Time to Make Your Voice Heard - Time to Vote!

[ original post ] 

Election Day is November 6th. But there’s another deadline you need to double check: October 12th is the last day for general voter registration. Are you registered? How about your friends and family members 18 years or older? Have you moved since the last election? Now’s the time to double check and make sure your vote counts.

In 2008, only 55% of people with disabilities voted in North Carolina, compared to 69% of people without disabilities. That means there was a 14% voting gap between voters with disabilities and voters without. Your biggest tool to affect positive change for the disability community is your vote. Make sure it counts!

Not sure if you can vote? Not sure if you’re registered? Not sure if you’re allowed to help someone at the polling station? Below you'll find information and resources you can use.

---

Disability Rights North Carolina has put together any number of tools you can use. Click here for a 2-page brochure that explains how to register, different ways to vote, and what to expect when you get there. Taking someone to the polls and want to support them while you’re there? Click here for information family, friends and poll workers can use.

Remember, you may register to vote if:

• You are a citizen of NC
• You have lived in the county/precinct where you want to vote for at least 30 days
• You will be 18 years or older on November 6, 2012
• You have not been convicted of a felony. (If you have been convicted, you’re eligible to vote as soon as you’ve completed all the terms of your sentence.
• You have not had the right to vote specifically taken away in any proceeding
• Most people with guardians keep the right to vote.

Even if someone challenges your right to vote, the law says the poll worker must allow you to vote on a provisional ballot. Don’t leave without casting your vote!

Click here to go to the NC Board of Elections website for more information on general voter registration, to double check your registration, and more.

Crisis in PCS in NC, & How to Address It

From The Arc of North Carolina

Crisis in Personal Care Services in NC, and How to Address It

[ original post ]

Issue:

For thousands of North Carolina citizens with intellectual and developmental disabilities (I/DD), as well as people with mental illness, the Medicaid State plan service "Personal Care" (or PCS) has provided supplemental funding for housing supports in small licensed group homes.

Earlier this year, the General Assembly raised the level of disability needed to receive PCS. Now, individuals must require assistance with three activities of daily living [ADL’s]. This rule applies to both in-home and facility based services, to achieve legally required comparability. Unfortunately, most individuals living in licensed group homes will no longer qualify.

This change could reduce a group home’s budget by up to 30%, creating significant budget shortfalls- yet another hardship for an already struggling community-based option.

Not only does this reduction affect the provider’s ability to provide basic support services, in many cases it could lead to an inability to meet the group home’s debt obligations. Many of these homes were financed using US Dept. of Housing & Urban Development (HUD) funding streams, and a significant number are tied together through HUD approved refinancing methods. If vacancy rates rise due to lack of support services, well over 250 properties could be at risk of failing.

Recommendations:

For most people living in these types of homes, PCS was not their most needed service. Individuals living in these settings most often need support services to allow them to live successfully in communities. For people with I/DD, they are most likely support services that are habilitative and for people with mental illness they would be recovery based support services.

For both populations there are Medicaid options that, if designed correctly, could support people in these settings and other community based options that should not increase the state funds needed to provide these supports. Unfortunately, it is impossible to get these new service definitions designed and approved by the Center for Medicaid Services by December 31- the end date of the current PCS definition.

With this in mind, we would recommend the following course of action.

1. Extend the state funds available to people living in Adult Care Homes to licensed group homes. Thirty-nine million dollars is already set aside for adult care homes during this period of transition. This reserve should be extended to licensed group homes as well. People living in licensed group homes often have more significant disabilities than the individuals in adult care homes and deserve the same protection provided by the funds appropriated for adult care home residents.
2. For people with IDD- Immediately begin the work of creating a specific 1915i option for services[s] that would support individuals living in community settings- both licensed and non-licensed. The 1915i option is a near perfect fit for this type of service. Not only can it provide funding to offset the loss of PCS, it could be designed to offset the state services dollars that are used in group homes and provide another meaningful Medicaid service for people living in other community settings. The match money for these services could come from already appropriated community base state funds. Preliminary estimates by The Arc indicate that a carefully crafted 1915i option could support individuals in these homes and make a significant dent in the waiting list without any additional appropriations from the State.
3. For people with Mental Illness– It is possible that the same type of 1915i option services may make sense for people with Mental Illness. It may be more difficult to craft services definitions that assure cost neutrality, but this option should be explored immediately.

At the same time, the state should review the possibility of creating a recovery-based support service under Medicaid that could be used in non-licensed community settings as well as licensed settings. Since Mental Health services are recovery based, such a service could be created without the use of a 1915i. In both cases, 1915i or state plan service funds already used for community services for people with mental illness could be used for match.

These recommendations are straightforward solutions to what will become a significant crisis if we do not act. While there may be other options, we suggest the above actions because they have to potential to solve the problem short term and create a low cost solution for the long term that is consistent with best practice. If we are able to follow this path we not only stabilize the licensed community based options but create good options for individuals who choose to live in less restrictive settings.

DOJ Settlement Good for People with Mental Illness, but May Leave People with I/DD Out

From The Arc of North Carolina

DOJ Settlement Good for People with Mental Illness, but May Leave People with I/DD Out

[ view at ArcNC.org ]

While it is too soon to know what the U.S. Department of Justice (DOJ) Settlement will mean for people with mental illness, now is the time to begin thinking about the effects it will have on our Mental Health/Developmental Disability/Substance Abuse (MH/DD/SA) system.

We appreciate the N.C. Department of Health and Human Services (DHHS) and DOJ finding a way to avoid costly litigation by reaching a settlement. While people can argue about the settlement’s details, there is really no question that NC’s placement of people with mental illness [and people with I/DD] in adult care homes is not appropriate. These settings were designed for people who are elderly, and are not settings where individuals who are young and have a disability will thrive. Spending large amounts of money defending a federal lawsuit would have been a true waste of taxpayer money.

The settlement does several things. The core of it requires the state to create new housing options [defined as slots]. These housing slots will include rental assistance and support services for 3,000 people, 2,000 that currently live in adult care homes, and 1,000 that are in jeopardy of being placed in adult care homes (or rest homes, as they are sometimes called) by 2020. It also requires the state to create, or increase, the availability of community services for people with mental illness including supported employment and additional Assertive Community Treatment Team services. The effort will have an independent monitor who will hold the state accountable. If the state fails to meet timelines, the DOJ can take the State to court.

One of the most disappointing parts of the Settlement is its lack of inclusion of people with developmental disabilities. Though the original complaint was about people with mental illness, there is no doubt that NC continues to rely upon similar institutional settings for people with I/DD. That people with I/DD were leftout of this settlement is concerning. Not only is the state allowed to continue its bias towards institutional settings in placements, community options made available to people with mental illness could come a the cost of community options for those with I/DD, given the State's limited resources.

Creating “scattered-site housing” is a great idea for all people with disabilities. The Arc continues to develop housing options that meet this criteria, but it is a slow process. We are also concerned that policy-makers in Washington and NC are adhering to conflicting policy in terms of housing and people with disabilities. One example is the HUD (US Dept. of Housing and Urban Development) funded properties The Arc manages for people with mental illness. Many of the properties are apartments that will not meet the scattered-site definition, yet have rental assistance vouchers as part of the project. Under the settlement agreement, very few of these properties will be available for people coming out of adult care homes. The changes that would be needed to make them available for these people currently run afoul of federal HUD regulations. We hope the DOJ and HUD will work together so future efforts will not exclude housing options promoted by federal agencies.

While the state has agreed to this promising settlement, we have significant related problems in our service system that must be addressed. One such problem is the crisis that will be created if we do not find a solution to the personal care issue. While the state will be creating community housing options for one group of individuals, others will be losing services and potentially their housing. This is not the way a system should work. While it is impressive that the General Assembly found funds to support the settlement, it should be noted that critical services are being sliced because of budget cuts at the same time.

While this settlement agreement is a step in the right direction, it is far from perfect. It does much for people with mental illness who have faced institutional bias, but at the same time it does nothing for people with I/DD facing a nearly identical problem. This is an opportunity for the leadership of the General Assembly and Administration to proactively take the spirit of this settlement and apply it to other populations. The best possible outcome is a more responsive system for all.

On Wednesday of next week the legislative Blue Ribbon Commission on Transitions to Community Living will hold its first meeting. Hopefully this committee will be the catalyst to create such change.

NC DHHS, US DOJ Reach Agreement on Community Based Care for Only Citizens with Serious Mental Illness

From The Arc of North Carolina

Breaking: NC DHHS, US DOJ Reach Agreement on Community Based Care for Only Citizens with Serious Mental Illness

[ view release at arcnc.org ]

Press Release from NC Dept. of Health & Human Services:

Raleigh — The North Carolina Department of Health and Human Services and the United States Department of Justice today reached an agreement on the state’s plan to offer more choices of where and how citizens with serious mental illness receive care and supportive services.

The plan, which was announced last month, will create housing slots in the community to offer the choice of community-based care for many adults with serious mental illness. It will also invest in job training and employment assistance for those citizens and will set up a comprehensive, 24/7 crisis care program for people with a serious mental illness.

This agreement will modernize our mental health system and ensure that North Carolina is providing the best possible treatment for adults diagnosed with severe mental illness. It will also provide the opportunity for many of these individuals to live in community settings if they choose to do so, and ensure that North Carolina is fully complying with the Americans with Disabilities Act and other federal laws.

This agreement is similar to ones signed by governors of a number of other states including, among others, the governors of Virginia and Georgia.

DHHS Secretary Al Delia agrees that more should be done to ensure access to community-based treatment for those with mental illness. “North Carolinians who have a serious mental illness have a right to choose the very best care environment to meet their personal needs,” he said. “That choice – whether they live in the community or in an adult care home – will be supported with access to mental health and other support services that will be available in part due to this agreement. Moving forward with a solution to help them identify and access those choices is the right thing to do,” he said.

“Disability Rights NC applauds the Governor and Secretary Delia for their leadership on this matter. They have not only done the right thing to protect the rights of people with disabilities, they have helped the state avoid costly litigation and destabilizing uncertainty,” said Vicki Smith, executive director of Disability Rights NC.

The agreement outlines DHHS’s plan of action to provide community-based services to people with mental illness. The budget the General Assembly passed in July expressly contemplated a settlement and appropriated funding to make this agreement possible. The timeline for completing the plan is eight years; this transition period will enable people who want to move to community-based settings to do so on a workable timetable and will allow sufficient time for North Carolina’s mental health infrastructure to implement this agreement.

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From Arc NC: Unintended Budget Cuts Must Be Fixed!

From The Arc of North Carolina

Unintended Budget Cuts Must Be Fixed!

[ view original posting ]

It’s time for the Governor and members of the General Assembly to fix the “unintended” reductions of the Social Services Block Grant (SSBG) for people with disabilities. Both legislators and the Governor’s administration seem to agree that an additional cut of $4.3 million to the community system was unintended. Unintended or not, this cut, on top of the $20 million intended reduction by the General Assembly, is causing serious harm to people with disabilities and their families.

It is hard do imagine that while the state is attempting to negotiate a settlement with the U.S. Department of Justice on ADA issues, we would allow further reductions to the fragile infrastructure of the community system. Services that allow people to live at home or in community residential settings are affected by this cut the most. Letting this “accidental” cut stand will hurt people.

The Arc, in a letter to the Governor, has asked that she take the lead on eliminating this cut. We are sending a similar letter to the House and Senate leadership asking them to join with the Governor to fix this unfortunate mistake. Hopefully, all parties will work together to do so.

Members can help by letting the Governor and General Assembly know that this cut must be restored. Let them know that our fragile community system cannot stand more reductions and that people with disabilities deserve better!

Contact:

• Governor Bev Perdue - governor.office@nc.gov (919) 733-5811
• Speaker Thom Tillis - Thom.Tillis@ncleg.net (919) 733-3451
• President Pro Tem Phil Berger - Phil.Berger@ncleg.net (919) 733-5708

From The Arc NC: Lessons from the Western Highlands Network overruns

From The Arc of North Carolina

Lessons from the Western Highlands Network overruns

[ view original posting ]

The cost overruns at Western Highlands Network (WHN), the first LME to become an MCO under a new law, are a serious issue. The solution to these overruns that the state and WHN has come up with is clear: further service cuts. Hopefully, these overruns are just a bump in the road and not the light of an oncoming train, indicative of a system-wide underestimation of managed care cost. Most likely it will be somewhere in the middle.

We can only hope that people with disabilities will not be harmed further by these overruns than they already have been by the shift to managed care. The Arc hopes WHN survives these problems and succeeds for the sake of the individuals they are in the business of supporting.

Regardless of the reasons for the problem, the State, meaning both the Administration and the Legislature, should be paying close attention. Though we do not yet know the specifics that led to these overruns, several things should be perfectly clear:

1. We need a real examination of the process. Regardless of why, no MCO should have such significant funding issues six months into operation. Some are understandably questioning the leadership of former CEO Arthor Carder, but it’s hard to believe anyone would question his commitment to the people WHN served, or the commitment of WHN’s staff. The fact that this MCO was allowed to go live without the tools to succeed is not only a mark on WHN, but more importantly a significant mark on the DHHS processes that deemed them ready.
2. We should not only examine the process that led to these overruns, but the 1915(b)(c) waiver model as a whole. It is no secret that The Arc does not believe this model is appropriate for people with IDD. The issues with WHN should cause public officials to question the model as well. As WHN looks for places to cut Medicaid rates, it becomes clear that the system prevents them from even considering state operated facilities [state institutions] for reductions comparable to community services. Managed Care was sold to legislators, and the public, on the assumption of MCOs’ ability to effectively manage all public resources. Clearly, that was not true then, nor is it now. This disconnect makes the state’s difficult transition to a new model of care even more difficult. If the 1915(b)(c) managed care model works for community-based services it should also work for state-managed facilities. This issue is just one of many model design questions that must be questioned.
3. State officials told the WHN Board that they should expect no additional state funds to make up for overruns. This begs the question: is the stated goal of “better access to services” just spin? When rate reductions, utilization reductions, and Medicaid paybacks are the primary tools used to eliminate deficits, it is difficult to take seriously that better access is a real goal. Better service access would more likely be achieved if the state were willing to adjust the capitation rate or infuse some money while WHN becomes better prepared to “manage.”

Though not enough details have been released yet to determine the specifics of the WHN overruns, we do know:

1. The only way “savings” will be achieved through this managed care model is through cuts. That should be clear as we review the differences in what WHN was paid and what they have said they needed to provide services. We know that Medicaid cost must be controlled but an honest discussion of how managed care achieves this is critical if people will have faith in this system.
2. The way “at risk” is used in this model is insulting to families, consumers and the people who provide the supports for them. Public MCO’s are not really “at risk” entities. They have raised no capital to fund their organizations; they receive generous administrative allocations separate from services funds, and have the ability to cut rates and services to consumers if they exceed budgets. Providers of services are the ones really at risk. With subjective decision making, constant rate reductions, no guaranteed “administrative” funds or excise payments to fund a MCO’s “risk” reserves, many providers will likely go out of business. Most importantly, people with disabilities and their families are the most at risk…at risk for another failed effort at reform jeopardizing their ability to live successful lives in the community.

I/DD Budget Cuts May Be Worse than Expected

From The Arc of North Carolina

I/DD Budget Cuts May Be Worse than Expected

[ original post here ]

In what is being described as a mistake, a budget transfer intended to move Guardianship funding from one division to another has created an additional 4.3 million dollar cut primarily to community services for people with I/DD.

Department officials and legislative leadership agreed to transfer $4.3 million in the Social Services block grant from the Division of MHDDSA to the Division of Social Services. The money was to be used by either Corporate Guardians or local DSS to provide guardianship services. The transfer was needed because, as LMEs transfer to MCOs, they will no longer be allowed to be guardian for individuals in their catchment areas.

Somehow the transfer of funding happened twice causing an additional cut of 4.3 million dollars to MHDDSA community services funding. Department officials tell us that this was never the intent and discussions with legislative staff point to a mistake, although we have no official confirmation. Unfortunately, the reduction has been included in the allocations to LME/MCO’s and several are taking immediate action to cut services. We are hearing reports that some programs face 20% reductions effective August 1st.

The Arc is calling on the DHHS to ask LME/MCO’s to hold off on implementing this reduction until all possibilities of fixing the problem have been exhausted. This reduction to an already fragile system is unwarranted and will harm individuals with I/DD.

The Arc is also concerned about how LME/MCO’s are implementing the one time $20 million reduction to community services. This cut is an extension of a reduction taken last year. While LME/MCO’s were encouraged to use fund balances to offset this reduction last year, we do not believe most did so. We are seeing a disturbing trend that has LME/ MCO’s passing on this entire cut to people with disabilities and their families. We believe a more responsive approach would be for LME/MCO’s to use fund balances to offset this reduction since it is a non-recurring cut. It does not seem appropriate for the Management Entities, who are charged with ensuring individuals have services, to use fund balances to become MCOs while the people they are created to serve lose services.

We will be tracking these reductions and will continue to encourage the State and LME/MCO’s to find alternatives to wholesale reductions for people with disabilities and their families.

Once we determine what steps the DHHS plans on taking, we will issue an action alert describing what actions people with disabilities and their families should take, if any, to influence these changes.

Related : 

• MCO Western Highlands Network estimates 3.5 Million Shortfall since January 2012.
• LME Smokey Mountain Center holds community forums regarding 3.4 Million Service Funding Reduction.
• Disability Rights NC Press Release : State fails to settle with DOJ but announces 8 year plan, 7/26.
• News and Observer article : LME Money Woes, from 7/18.

First LME to become MCO Facing Budget Overruns

From The Arc of North Carolina

First LME to become MCO Facing Budget Overruns

[ view original article ]

Western Highlands Network (WHN), the Managed Care Organization (MCO) that provides state funded services to people with intellectual and developmental disabilities (I/DD) in several western counties, recently reported that they are running a monthly defecit of $500,000 since they became a managed care organization in January 2012. WHN officials indicate they feel the State’s original capitation (reimbursemnt) rate was insufficient to cover the Medicaid cost of their program.

When questioned by members of the Disability Waiver Advisory Committee on July 24th, State officials responded that the budget deficit had been uncovered in a routine monitoring visit and that they would be attending the upcoming WHN board meeting. They offered no further explanation.

Apparently the State, along with the Mercer consulting firm, reviewed WHN in mid -July to determine what was causing the cost overruns. At this time, we do not have the results of this review, but we will report as we find more details.

The revelation of these cost overruns is concerning on many levels. Most importantly, we are concerned WHN will be forced to make significant cuts to services in an area that already has significant numbers of people with I/DD waiting for services. To correct this deficit, WHN plans to evaluate rates paid to providers and the amount of service provided to consumers. If this problem results in service reductions, it will be further evidence that Managed Care “savings” are really just another name for “cuts.”

If the capitation rate is too low, as WHN claims, and the state adjust it upwards, it will erode the “savings” North Carolina hopes to gain from the implementation of the Managed Care Waiver. Such a development would call into question why we would make such a massive change for little gain.

Another concern is how the state deems a MCO ready to proceed. According to state officials, all pending MCOs pass rigorous tests to assure that they are ready to go “live” as a managed care entity. The State contracts with Mercer to engage in this process, as do state officials charged with implementing the Waiver. If WHN was really ready to go “live” in January, it is hard to believe they could be losing money at such a pace.

The Arc believes the WHN staff and DHHS staff are sincerely attempting to find solutions to this serious problem. We hope that this issue is only temporary and that services will not be disrupted to the people this complicated system is intended to serve. However, we do believe this issue should prompt the DHHS and the General Assembly to truly examine the model and pace of this implementation. In an at risk Managed Care system, the only people truly at risk are the people it is intended to serve.

Arc NC's Legislative Summary

From The Arc of North Carolina
Legislative Summary regarding Developmentally Disabled Populations of North Carolina

[ original post ]


In this year’s legislative session, the General Assembly adjusted the budget, created policy direction in the budget, and passed important policy bills. The Arc worked on and monitored many issues of importance to people with intellectual and developmental disabilities as well as their families during the session. Below we have provided a brief recap of some of the most important issues.

Kindergarten Developmental Screening

Kindergarten Developmental Screening is part of the new budget bill (H950, which was passed by the General Assembly, vetoed by Governor Perdue, whose veto was then overridden, making the bill law). Section 115C-83.1 E orders the State Board of Education to ensure that every student entering kindergarten shall be administered a developmental screening of early language, literacy, and math skills within 30 days of enrollment. Section (e) states that the assessment shall be reliable, valid and appropriate for use with all children, including those with disabilities.

NC Teaching Corps to Include Disability Training

The new budget bill (H950, which was passed by the General Assembly, vetoed by Governor Perdue, whose veto was then overridden, making the bill law) establishes the North Carolina Teaching Corps, a training program for those who wish to become teachers via lateral entry (in other words, for those whose degree is not in teaching). The program is to include training on identification and education of students with disabilities, positive management of student behavior, effective communication for defusing and de-escalating disruptive and dangerous behavior, and safe and appropriate use of seclusion and restraint.

Personal Care Services and Short Term Rental Assistance to Adult Care and Group Homes

Personal Care Service (PCS) is a Medicaid funded service aimed at assisting individuals with disabilities with activities of daily living. Currently people who have Medicaid and live in a licensed residential setting receive one hour a day of this service.

The General Assembly choose not to follow the DHHS recommendation to create a 1915i option to address federal Medicaid officials’ concerns around Personal Care Services. The 1915i option is a relatively new Medicaid option for states to use. It allows for states to put in place Medicaid home and community based services without a Medicaid waiver. The Arc believes this option would best used to expand community based services for people with IDD.

Instead of following DHHS recommendations, the General Assembly passed language that will require DHHS to create a new Medicaid state plan amendment creating a comparable PC service for individuals living at home and in facilities. This impacts people living in Group Homes and Adult Care homes. The Arc has concerns that the new plan will eliminate PCS for some people (we are attempting to determine the scope), which could cause significant service reductions.

As part of H950, the Modify 2011 Appropriations Act, the State provided $39.7 million of non-recurring funding to provide temporary rental assistance to adult care homes. These funds will help pay rent at adult care homes for residents who are no longer eligible to receive Medicaid reimbursable personal care services (PCS), but for whom a community placement has not yet been arranged. Unfortunately, this fund will not assist residents who live in group homes and lose PCS. One of The Arc's top priorities for the interim will be to work with DHHS and the legislature to assure people living in group homes are not adversely affected.

Community Service Funding Cut

There was a $20 million non-recurring cut to community services funding. Approximately $345 million in State general funds remain in the budget for LME/MCOs to purchase community based services.

The Arc is disappointed in this cut. The original Senate budget had no cut in this area, and the original House budget had only a $10 million dollar cut. The change was made only two days before the final budget bill passed, giving little time for input from The Arc, other advocacy organizations, and families. We hope the General Assembly will restore this much needed funding during next year’s budget session.

Money for Transition to Community Living

As part of H950, the Modify 2011 Appropriations Act, the State allocated $10.3 million in recurring funding to speed up the transition of individuals with severe mental illness to community living arrangements, including establishing a rental assistance program. Some of the impacted individuals are dually diagnosed with a developmental disability as well. We believe this funding was allocated to respond to a potential negotiated settlement with the US Department of Justice (US DOJ) over North Carolina's use of Adult Care Homes as placements for people with Mental Illness, which it says violates Medicaid law.

Medicaid Shortfall Bills

There was a great deal of press surrounding the multi-million dollar Medicaid budget shortfall for the 2011-2012 fiscal year. The shortfall, initially estimated at $205,500,000, was addressed by S797 (Payment of 2012 Medicaid Costs/Inmate Medical Costs) early in the session. S797 drew funds from receipts, unanticipated federal bonus money, and Repair & Renovation Reserve Funds for the University of North Carolina System.

Unfortunately, in the last few weeks of the legislative session, it became obvious that there was an additional gap in Medicaid funding of approximately $94 million. To address this gap, the General Assembly passed H14, the Use R&R Funds for 2011-2012 Medicaid Costs Act. This bill appropriated $94 million from the Repairs and Renovations Reserve Account from the UNC System be transferred to the state controller. The controller was to manage Medicaid funding for the remainder of the 2011-2012 fiscal year.

LME/MCO Governance Bill(s)

HB1075 came out of the House subcommittee that studied the LME/MCO Governance issue led by Representative Nelson Dollar. It dealt with rules governing the makeup of LME/MCO Boards of Directors. The bill as proposed by the sub-committee, while not perfect, was a compromise reached with input from most stakeholders in the MHDDSA system. After the bill passed the House, Sen. Fletcher Hartsell added a controversial amendment to the bill would have allowed LME/MCOs that had been operational for three years to become “Behavioral Health Authorities.” This new classification significantly changed the method of accountability and operation of the MCO system. Most advocates, including The Arc, opposed these changes due to serious concerns on how the LME/MCOs’ new authority would impact people with disabilities and their families.

Ultimately, some legislative maneuvering resulted in a new bill (S191, LME Governance) that included the original Board member rules, excluded the Behavioral Health Authority amendment, and allowed for MCO's with over 1,200,000 people to create new board structures, if approved by the Secretary of DHHS.

Parents as Providers

As many of you know, there were quite a few changes made to rules surrounding parents as providers. These changes were by and large not changes in laws, but in administrative rules. The Arc is very concerned with these changes and will delve into the problems around this and related issues in the near future.

The following bills did not become law this past session

The Arc's Proposed Changes to H916
Though our proposal did not receive formal consideration, we were pleased with the broad based legislative support it received. We believe that the majority of legislators now understand why it is important to have an independent person working with families and individuals to write their Person-Centered plan. In a future addition of Policy Partners, we will discuss in more detail why this proposal continues to be a critical component if managed care is to be successful. For now, we want to thank you for your incredible advocacy efforts you undertook towards making these changes. Your voice was heard!

Eugenics Compensation Bill (Did Not Pass)

This bill would have set up a fund to reimburse victims of forced sterilization at the hands of the State. A large percentage of NC’s sterilization victims were individuals with intellectual or developmental disabilities. The bill passed the House, but was not taken up in the Senate.

On a somewhat brighter note, a last minute compromise between the House and Senate provided funding for the Eugenics board to continue its work during the 2012-2013 fiscal year.

Incapacity to Proceed (Did Not Pass)

If a person with I/DD is arrested, they (like everyone else) go to jail while they await a bail hearing/trial. Often, people with I/DD are found to lack the capacity to proceed to trial, and are sent to an institution for treatment. Often, they eventually reach a point where they are deemed capable to proceed with their trial, at which time they are sent back to jail, and their trial is put back on the schedule. Once back in jail, the person with I/DD often regresses, is once again deemed incapable to proceed, and is sent back to an institution for treatment as the cycle continues. There are documented cases of individuals with I/DD arrested for a crime spending far longer (years even) bouncing back and forth between treatment institutions and jail before trial than they would spend in jail if they were tried and convicted.

H1048 would of made outlined clear steps to avoid this type of situation for both misdemeanors and felonies. This bill passed by an overwhelming margin in the House (114-0), but was not taken up in the Senate. Representative Pat Hurley has said she will file this bill again in 2013.

We are disappointed that the Senate chose not to put such an important and widely supported bill on this year’s agenda, and hope they choose to take it up in 2013.

Voter ID Bill (Veto was not overridden)

Originally, The Arc worked extensively with Representative David Lewis during the 2011 long session on what became known as the Voter ID Bill (H351, Restore Confidence in Government). We tried to address the many concerns that existed in the disability community around the topic of voter ID. While we came up with compromise language that would of addressed most of our concerns, unfortunately the compromise language was ultimately stripped from the version of the bill. This stripped down version of the bill passed the General Assembly and was vetoed by Governor Perdue in 2011.

While an override attempt of this bill was on the calendar throughout the short session, it never happened. The bill is dead for this year, but a new version of the bill is expected in 2013. We again will work diligently with the bill sponsors to ensure that the concerns of people with disabilities will be addressed.

N&O: LME Money Woes

Money woes snag mental-health center

Published Wed, Jul 18, 2012 09:38 PM
By Lynn Bonner - lbonner@newsobserver.com
The News and Observer

[ original article ]

The state’s latest plan for community mental health services has gotten off to a bad start with the first local mental health office to become a managed-care agency falling into a $3 million financial hole in its first six months of operation.

Western Highlands Network, which covers eight counties including Buncombe and Rutherford, is working with the state Department of Health and Human Services on a plan to correct the money problems that started the first day it became a managed-care agency in January.

The changes may involve reducing some mental health treatments the office believes are excessive, telling service providers to return money for services that were not approved, and enforcing rules for providers filing payment claims.

The experiences in the west are significant because, under a new state law, all government-paid mental health services in the state will be handled the way they are in Western Highlands. Advocates for people with disabilities are skeptical that the new system will work, and they worry consumers will be the losers.

Last year, the legislature passed a law that requires all local mental health offices to convert to managed-care agencies by January 2013, copying a system started in the state in 2005 by Piedmont Behavioral Health, a local mental health office now called PBH.

As managed-care agencies, the local mental health offices’ relationships with the state, mentally ill people in their coverage areas, and providers will change significantly. Each local office will be given a set amount of Medicaid and state money to treat patients. If they spend too much, they have to cover the costs. Local offices that save money can spend it on more Medicaid mental-health services.

Though the local offices take on financial risks, they also have more control. Under managed care, they will say which providers will treat patients in the region and what kinds of treatment – and how much government-paid mental-health treatment patients receive.

Choice and uniformity

This is the biggest change to mental-health services in the state in more than a decade. In 2001, the state told local offices to stop offering treatment in favor of having patients seek out private providers. The intent was to give patients more choice and foster uniformity across the state.

That 2001 reform was an expensive failure. Patients were left waiting for beds in state psychiatric hospitals while the state spent millions on low-level services for people who didn’t need treatment. A legislative report from 2009 said the state spent up to $635.3 million too much for community mental-health services between April 2006 and February 2009.

Legislators talked for years about giving more local offices more power and passed a law last year requiring it. Western Highlands was the first regional office to convert. Two more offices have followed. All 11 local offices will be managed-care agencies by January 2013. The office covering Durham and Wake counties will be in the last group converting.

The local offices do extensive prep work before they convert and a consulting firm assesses their readiness to switch.

Outdated figures


Western Highlands has been losing money all year. One of the problems, said CEO Arthur D. Carder, is that the lump-sum payment the office received to care for patients was based on outdated information from 2009 that did not take into account increased costs in 2010 and 2011.

Al Delia, the state Department of Health and Human Services acting secretary, said the office has been closely monitoring Western Highlands and is talking about taking another look at whether the $9.7 million a month the office receives to pay for patient treatment is enough.

Delia was in the western counties Wednesday, meeting with members of the office’s governing board.
“There’s going to be some adjustment in culture and attitudes and mindset in leadership of all these organizations in making these transitions,” Delia said.

Skeptics question whether managed care is the best system for all consumers.

“I think we’ve rushed to judgment on this,” said Dave Richard, executive director of The Arc of North Carolina. Parents of children with developmental disabilities and the agencies that provide services to the disabled have been among the most vocal skeptics of managed care, questioning conversion to a system they say isn’t designed to meet their needs.

“If you’re going to give up the system where people had a lot of choice to one where choice is limited and is controlled by one entity, you’d hope to see better outcomes,” Richard said. “We haven’t seen that with folks with developmental disabilities.”

Lawsuit under way

State officials and legislators have looked to PBH as an example for years, but not everyone is a fan.
Disability Rights North Carolina, an advocacy group, is suing PBH in federal court over allegations that it did not give residents proper notice of changes in their services or let them know how they could appeal.

Western Highland’s problems show that the office wasn’t ready to become a managed-care agency, said Vicki Smith, Disability Rights’ executive director.

“It would almost be too simple to say this was predictable,” she said.

Legislators are convinced that managed care is the path to follow for mental-health care. The legislature is committed to a new system where government does more than just pay the bills, said Rep. Nelson Dollar, a Cary Republican.

“We want to manage the care and the individuals receiving the care, and manage the costs and how we’re allocating scarce taxpayer resources,” he said.

Legislators have been working with DHHS since winter on Western Highland’s financial problems, Dollar said. A new law that adds members with experience in managed-care finances, insurance and health care administration to local governing boards is meant to strengthen oversight of Western Highlands and other managed-care operations.

“We’re going to be working with the department to straighten out issues like the ones that are being encountered in Western Highlands and making sure what lessons are learned there are being incorporated in the conversions in other areas of the state,” he said.

Speaking Notes from 6/8 I/DD System Leadership

Earlier last month, June 8th, I attended the NC Behavioral Health and I/DD System Leadership Congress at UNC Chapel Hill with the Jordan Institute for Families and spoke as a consumer parent. 

This leadership "summit" as I like to think of it, was an brilliant idea and effort to bring together all the powers that be in North Carolina's Mental Health, Developmental Disabilities, and Substance Abuse Services systems for a day of laying aside our egos and finding common ground. Among the rules: "No shame, No blame, and No enemies"...

It is my understanding that the late Steve Jordan, Director of North Carolina's Division of Health and Human Services, was instrumental in manifesting this vision.

Below are my speaking notes from that day...

I'm proud to say there were many tears as I walked away from the microphone, followed by numerous hugs. --Those tears gave me hope... It is our humanity that connects us and without that, we are all lost.

Speaking Notes

When I was invited to participate in this “summit” – a gathering of intelligent minds and caring souls for an active listening dialogue toward a common good, I thought, “What a novel idea!” and so wore today the closest thing I own to bellbottoms! So please pardon my casual appearance; it is my day off. –I understand we’ll be roasting marshmallows afterwards.

Rather than tell MY story, I’m going to do something a bit different. 

I’m going to tell A story…

Could our video guys please dim the lights a little; as low as you can still record?

Thank you.

Most of you raised your hands at the beginning when asked if you knew someone or had someone in your family affected by mental health issues. Most of you are probably parents as well.

Think of these people now: those you know and your own children…

Let’s take just a moment here to STOP… 

I’d like for you each to close your eyes… take a deep breath and imagine, just for a brief instance, that you are not a State Director nor Department Representative, not a Policy-maker nor LME, nor Provider; you’re not an elected official, not a politician, nor even a party affiliate – it’s not that you don’t care what’s going on in the world around you, but your world demands all of your time and energy... 

You are only an expert in what you know: your life, your family, your children.

Imagine that you’re just an average North Carolinian living paycheck to paycheck trying to be the absolute best parent you can be providing for a child you never anticipated; a child you would give your life for just to hear them speak the words, “I love you.” 

You juggle all your time between coordinating and attending appointments with doctors and specialists and therapists, attending IEP, ESY and CNR meetings and a whole host of other acronyms, working to provide for your family, feeling guilty over the lack of “normalcy” and opportunity left over for siblings, researching special education law and medical issues, catching up on missed work, catching up on missed life, neglecting your own needs, networking with other parents searching for answers and sharing resources, learning sign language, physically caring for your special child, giving injections, changing g-tubes and adult diapers, and fighting for their rights – against the school, against the county, against a library that discriminated against your child, against the State who threatens not just their livelihood and quality of existence… but the very ability to LIVE.

You pray, you cry, you curse, you question… and you pray and cry some more.

You stopped thinking long ago about providing a better life for him or her than you once had; you only want what’s right and just and to not have to wake every single morning wondering that which haunts you to your core, “What would happen to my child if something happened to me?”... Just for a second, please imagine, please consider, what if this were your child? 

And this is only a tiny intimate glimpse into one perspective among many, many distinctly unique personal challenges and needs. There are countless more individual lives with different experiences, different abilities and different needs – as different as our own fingerprints.

I maintain – the Human Element is missing. In the shared passion and determination to make a difference, we have lost sight of our reason for being here. THAT is our disconnect. And the human element is what connects us ALL.

We are NOT afraid of change. Our lives ARE change.

What we’re afraid of is FAILURE:

• Of failing the potential and purpose of each and every individual, regardless of need or ability. 
• Of failing Ourselves. 
• Of failing the children who emanate love and spirit unconditionally and at the end of the day, keep it real. 
• Of failing those we love and care far: 
• Who are fragile, 
• Who are in need, 
• Who are struggling to maintain, 
• Who desperately DESIRE to BE, 
• Who are INTENDED to BE. 

We are ALL INTENDED to BE.

Everyone has something to teach… My daughter Isabel is my greatest teacher.

What can we learn from one another? 

We are ALL EXPERTS in OUR OWN LIVES and it IS PERSONAL.

And NONE of us can afford NOT to get this right on this level of magnitude…

How do we fix it?

Thank you.

Crystal J. De la Cruz - Hopper 

Special Mom, DD Advocate, & Concerned NC Citizen 

June 8, 2012 Leadership Congress

From The Arc of NC

Despite overwhelming support from families and people with disabilities across North Carolina, it appears the NC General Assembly will not act on The Arc’s proposal to restore balance in our state’s Managed Care Organizations. Without action, individuals with intellectual/developmental disabilities (I/DD) and their families will no longer have someone other than the Managed Care Organization write their person centered plan (plan of care), unless the MCO chooses to allow that option. Currently, no MCO in the state plans on offering this option. This means that plans of care for people with I/DD will continue to be developed by the same organization that determines how much funding an individual will receive.

Though our proposal faced long odds in the legislative short session, many legislators expressed support for the proposal. Unfortunately, erroneous information on the costs of our proposal given to legislators by certain MCOs, combined with the efforts of powerful lobbyists employed by some MCOs, proved too difficult to overcome. While there is still time for the legislature to act, it is unlikely any action will take place before their adjournment this week.

The lack of action will result in an additional ten thousand people with I/DD losing Case Management Services by January 2013, without the benefit of an independent broker working for them and not the MCO. Additionally, hundreds of private sector jobs will be lost while MCOs expand their workforce.

The legislature's lack of action is particularly disappointing since The Arc attempted to make our proposal fit what legislative leaders suggested. Though we believe a more robust private Case Management system makes sense for people with I/DD, we adjusted our proposal to the more limited two functions of Care Coordination. Legislative leadership needed a state budget neutral proposal, and our proposal would not increase the state budget. Our efforts were a sincere attempt to modify a model that is not a good fit for people with I/DD before the model was implemented statewide. The fact that legislators were unwilling to address these issues is very disconcerting.

While terribly disappointed in the outcome, we are pleased that so many spoke out for what is right for people with intellectual and developmental disabilities. Over 1100 North Carolinians from all parts of NC signed the petition to support this proposal with over 200 heartfelt comments about their situation. Hundreds of families called their elected representatives and participated in legislative meetings, making elected officials aware of the serious concerns they have about the future of our system.

The Arc encourages MCOs to listen to people with I/DD and their families in the coming months and contract with independent care coordinators to write plans and link to services, as is allowed under current law. Such a model, designed appropriately, will provide much needed support and be cost effective.

Regardless of the ultimate outcome of this legislative session, The Arc will continue its efforts to modify the State’s plan for Managed Care for people with I/DD. We believe legislators and administration officials, when properly informed, will see the flaws in the design of the current system for what they are and make appropriate changes.

We encourage families and consumers to continue to voice your concerns to legislators and the administration through all available channels. The Arc will begin publishing information on how best to influence the managed care Waiver implementation beginning in early July.

For now we want to thank all of you for your incredible advocacy this year! While not having our proposal adopted is disappointing, your actions significantly altered the debate around HB 916 in the legislature. Your voice will be needed more than ever as this transition moves forward.