SB 191 v 4: LME Governance

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! 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.

From: MaryKShort@aol.com
To: andrew.brock@ncleg.net, austin.allran@ncleg.net, dan.soucek@ncleg.net, doug.berger@ncleg.net, eric.mansfield@ncleg.net, fletcher.hartsell@ncleg.net, james.forrester@ncleg.net, jim.davis@ncleg.net, louis.pate@ncleg.net, martin.nesbitt@ncleg.net, ralph.hise@ncleg.net, stan.bingham@ncleg.net, tommy.tucker@ncleg.net, william.purcell@ncleg.net
CC: bert.jones@ncleg.net, beverly.earle@ncleg.net, bill.current@ncleg.net, fred.steen@ncleg.net, harris.blake@ncleg.net, justin.burr@ncleg.net, marian.mclawhorn@ncleg.net, marilyn.avila@ncleg.net, mark.hollo@ncleg.net, martha.alexander@ncleg.net, nelson.dollar@ncleg.net, mitchell.setzer@ncleg.net, pat.hurley@ncleg.net, rayne.brown@ncleg.net, shirley.randleman@ncleg.net, tim.moffitt@ncleg.net, Tillisla@ncleg.net, tom.murry@ncleg.net, tricia.cotham@ncleg.net, william.brisson@ncleg.net, MaryKShort@aol.com, Candace.SlateRep.Dollar@ncleg.net
Sent: 6/28/2012 10:43:35 A.M. Eastern Daylight Time
Subj: SB 191 v 4: LME Governance


To all: Dr. Porter wrote a dissertation in response to my email to you all. Her statement that the courts have somehow ruled against "family guardians" is a willful misrepresentation of the issue. She states:

"... the district court ruled that it was not in the best interest of the citizen for the agency that managed their service money also served as their guardian."

Please. Family guardians do no NOT manage their ward's service money! Just take out (f). It's not in existing guardianship laws now and it just doesn't need to be in there at all at this time. Again, study it, have hearings, etc. Just please take it out of SB 191 v 4.


And just so you all know, please see the email below. I added the RED.

From: Goda, Deborah A [mailto:deborah.goda@dhhs.nc.gov]
Sent: Tuesday, June 26, 2012 2:12 PM
To: Creative Case Management
Cc: Crosbie, Kelly
Subject: RE: [SMC Communication] Monday June 25, 2012 (SMC Communication: #80) 

Good afternoon, Kathy. 

The applications are for Relative and/or Legal Guardians. The provider of Residential Supports may be the Legal Guardian in an Alternative Family Living Arrangement; please note that this an out of home living situation.
Please let me know if I can be of further assistance. 

Deb Goda 

IDD Services Consultant
Clinical Policy
DMA
919-855-4297
deborah.goda@dhhs.nc.gov

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

In a message dated 6/27/2012 5:03:20 P.M. Eastern Daylight Time, Candace.SlateRep.Dollar@ncleg.net writes: 

From: Patricia Porter (Mental Health)
Sent: Wednesday, June 27, 2012 04:54 PM
To: 'MaryKShort@aol.com ' 

Cc: Rep. Nelson Dollar; Sen. Andrew C. Brock; Sen. Austin Allran; Sen. Dan Soucek; Sen. Doug Berger; Rep. Mitchell Setzer; Rep. Pat Hurley; Rep. Rayne Brown; Rep. Shirley B. Randleman; Rep. Tim Moffitt; Joe Nolan (Rep. Tillis); Rep. Tom Murry; Rep. Tricia Cotham; Rep. William Brisson; Sen. Eric Mansfield; Sen. Fletcher Hartsell, Jr.; Sen. Jim Davis; Sen. Louis Pate; Sen. Martin Nesbitt; Sen. Ralph Hise; Sen. Stan Bingham; Sen. Tommy Tucker; Rep. Beverly Earle; Rep. Bill Current; Rep. Fred Steen; Sen. Harris Blake; Rep. Justin P. Burr; Rep. Marian McLawhorn; Rep. Marilyn Avila; Rep. Mark Hollo; Rep. Martha Alexander; Sen. William Purcell; Rep. Bert Jones 

Subject: RE: SB 191 v 4: LME Governance 

Hello Ms. Short, 

Your message has been forwarded to me for reply. 

As you know, in the original Local Management Entity(LME) Governance legislation language ( H1075) passed by the House, Guardianship was addressed in detail. The DHHS requested that we insert this clarifying language in that the courts had ruled that the LME/MCOs could no longer serve as guardians for people with mental illness, developmental disabilities or substance abuse disease due to a conflict of interest. While these LMEs had served for many years in this capacity, the district court ruled that it was not in the best interest of the citizen for the agency that managed their service money also served as their guardian. 

Taking the lead from the courts the state has moved to protect against conflict of interest. The state has an abiding interest in assuring that adults who receive services are provided with guardians who are not also responsible for being the paid provider of services. This prohibition has been in the Guardianship language in H1075 from the beginning.
Wisely, the DHHS called attention to the fact that there are about 200 parents of people with developmental disability who have elected to become paid providers of services for their adult children. Many of these parents, such as yourself, also serve as guardian for their adult child. In an effort not to disrupt this arrangement, the General Assembly amended the Guardianship language to designate paid parent service providers as exempt from this conflict of interest prohibition. 

In further discussion by the House HHS Committee, members posed the possibility of other family members being in a potential conflict of interest. In an effort to address this concern, while continuing to protect the best interests of adults with disabilities in the state, an amendment was proposed that will allow all immediate family members of an adult consumer who, before Jan 1,2013 are serving as both paid service provider and guardian to be able to continue to do so. However, there is also a recognition that this situation deserves more scrutiny. Accordingly, the provision that you have included in your message was provided to the House yesterday and that body voted in support of it. To formalize the process for review of this issue, a technical amendment was added to the budget bill today directing that a study of Guardianship will be added to the list of items for review by a subcommittee to be established by the Joint HHS Oversight Committee during the interim before the long session. This amendment can be found under Section 10.11 (a). Contrary to your assertion that this had not been a well thought out process, the General Assembly wants to make sure that knowledgeable individuals can carefully review the facts about this issue and come to a set of recommendations that will guide future actions on this issue. 

I hope this is helpful to you. Please let me know if I can provide additional assistance. 

Pat Porter 

Patricia Porter, PhD, Consultant
Health and Human Services
North Carolina General Assembly
301-B Legislative Office Building
300 N. Salisbury Street
Raleigh, NC 27603
(919)301-1982

From: MaryKShort@aol.com [mailto:MaryKShort@aol.com]


Sent: Wednesday, June 27, 2012 12:58 PM
To: Sen. Andrew C. Brock; Sen. Austin Allran; Sen. Dan Soucek; Sen. Doug Berger; Sen. Eric Mansfield; Sen. Fletcher Hartsell, Jr.; Sen. James Forrester; Sen. Jim Davis; Sen. Louis Pate; Sen. Martin Nesbitt; Sen. Ralph Hise; Sen. Stan Bingham; Sen. Tommy Tucker; Sen. William Purcell
Cc: Rep. Bert Jones; Rep. Beverly Earle; Rep. Bill Current; Rep. Fred Steen; Sen. Harris Blake; Rep. Justin P. Burr; Rep. Marian McLawhorn; Rep. Marilyn Avila; Rep. Mark Hollo; Rep. Martha Alexander; Rep. Nelson Dollar; Rep. Mitchell Setzer; Rep. Pat Hurley; Rep. Rayne Brown; Rep. Shirley B. Randleman; Rep. Tim Moffitt; Joe Nolan (Rep. Tillis); Rep. Tom Murry; Rep. Tricia Cotham; Rep. William Brisson
Subject: SB 191 v 4: LME Governance


I DO NOT AGREE with the proposed language found on page 8, (f) regarding Guardians and parents and other family members. I urge you to simply delete it ALL. I do AGREE with there being a "study" to determine what should happen going forward, but that the NCGA should leave well enough alone UNTIL AFTER THE STUDY! This is all too rushed and not heard or debated in committee or committees.


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

From: MaryKShort@aol.com
To: MaryKShort@aol.com
Sent: 6/27/2012 12:38:46 P.M. Eastern Daylight Time
Subj: URGENT TODAY: Language change re Guardians!

Here we go! The NCGA changed the LME Governance bill number from HB 1075 to SB 191. You need to care about this because NEW LANGUAGE WAS ADDED ABOUT GUARDIANS AND FAMILY MEMBERS WHO ARE ALLOWED TO BE PAID TO PROVIDE SERVICES. My comments are inserted in blue, after the sentence in question.


What this says is that after January 1st, 2013, NO FAMILY MEMBER WHO IS NOT A PARENT, BUT WHO IS A GUARDIAN WILL BE ALLOWED TO BE PAID TO PERFORM ANY SERVICES. Going forward, if you, the parent, falls over dead after January 1st, 2013, any family member you have ready to become the Guardian, WILL NOT BE ALLOWED TO BE PAID TO PERFORM SERVICES. As long as the family member is NOT A GUARDIAN, they may be paid to perform services.

(f) An individual who contracts with or is employed by an entity that contracts with a local management entity (LME) for the delivery of mental health, developmental disabilities, and substance abuse services may not serve as a guardian for a ward for whom the individual or entity is providing these services, unless the individual is a parent of that ward. (That first sentence is fine.) The prohibition provided in this subsection shall not apply to a member of the ward's immediate family who is under contract with a local management entity (LME) for the delivery of mental health, developmental disabilities, and substance abuse services and is serving as a guardian as of January 1, 2013. (This is vague. It should have the same language as the first sentence: ... immediate family who contract with or is employed by an entity who contracts with a local management entity (LME) ...) For the purposes of this subsection, the term "immediate family" is defined as a spouse, child, sibling, parent, grandparent, or grandchild. The term also includes stepparents, stepchildren, stepsiblings, and adoptive relationships."

[ Read more: Mary's full original email here. ]

email from Dr. Pat Porter

09 April 2012

Received via email from Dr. Pat Porter, DHHS consultant to the NC General Assembly:

Hello Crystal, I followed up on your question regarding the rates of pay for direct care workers per the changes in approved service definitions.  While this seems to be resolved for now, there were a couple of issues that caused some confusion with the transition of ECBH to the B-C Innovations Waiver.

The CAP IDD waiver is not a perfect crosswalk to the Innovations waiver.  In the CAP Waiver, recipients have had access to Home and Community Support (HCS), which is primarily a habilitative  service with a very small amount of personal care (PCS) blended in.  (CAP IDD also has the basic PCS).  So, HCS in CAP cross-walks to In-home Skill Building and PCS in the Innovations waiver.   In-Home Skill Building (a hab service) pays more than PCS.

As ECBH was cross-walking the services during transition, they cross-walked much of the HCS to PCS, rather than In-Home Skill Bldg.   Again, HCS/In-Home Skill Bldg. pays a higher rate than PCS.  But, there was a reason for this. ECBH could find very few habilitation  goals on the plans being reviewed and, unfortunately,  they found little or no evidence of assessments supporting the recipient's ability to benefit from habilitation.  Based on the assessment information they found, it appeared that most recipients were actually receiving more PCS than hab. As you know, the Managed Care sites  must pay for the actual services needed and rendered.

With further review and technical assistance from the Division of Medical Assistance,  ECBH elected that the wisest course of action on behalf of their consumers would be to cross-walk HCS directly to In-Home Skill Bldg for ease of transition.  I am told that these cross-walked plans will last for the remainder of the plan year.  This is the action that had already been taken by Western Highlands and PBH as they made these transitions.  I am told that ECBH alerted the providers in a March 22 Communication and in a town-hall meeting in Greenville but, apparently, not everyone has gotten the word yet.

At some point soon, ECBH will be compelled to address the  habilitation/PCS issue. Perhaps this will occur in Annual Revisions. Care Coordinators have been alerted to pay attention to additional assessments that may be needed to support habilitation goals.  Be assured that the Care Coordinators will develop plans based on what the recipient needs and wants ( that’s the rule). Utilization Management may, however, deny a habilitation service if there is not demonstrated medical necessity per CMS rules.  Certainly, if that should occur, ECBH will offer review and appeal rights. The DHHS will be monitoring the process to assure due process.

This is a long reply but I hope it is helpful to you

email from Dr. Pat Porter

March 6, 2012

Response via email:

From: Dr. Patricia Porter, UNC adjunct Professor / DD and Policy Expert / hired Consultant to the NC General Assembly:


Hello Ms. De la Cruz-Hopper,

It was a pleasure to speak with you last week. As you know, Senator Hartsell and Representative Dollar asked that I contact you in response to the letter you sent to Governor Perdue and copied to members of the General Assembly. They were impressed with the comprehensiveness of your representation of your daughter’s status and the struggles you have had assuring that she receives the services and supports she needs as well as your concerns about issues that you have heard and read that may come from changes related to the statewide implementation of the Medicaid B-C Managed Care Waiver. You surely have done your homework and I believe you have done your best to become well informed about the changes to come in our MH-DD and SA system of services.

As you noted at the end of our conversation, there is a good bit of misinformation coming out about these planned changes and in some instances, an absence of factual information for families. As your own LME ( Wake) proceeds to prepare for the transition from a fee-for-services to a managed care operation, you are wise to make sure that you are being made aware of these plans and the potential impact of the changes. I understand that information and discussion opportunities are being planned and there is a request for questions currently posted on the Wake website. http://www.wakegov.com/humanservices/waiver/questions.htm

You may know that the session law (attached) directing the statewide expansion of the B-C Waiver has a number of specific provisions that require both the Department of Health and Human Services and the Local Management Entities to assure that the system is structured so that stakeholders, such as yourself, have meaningful knowledge of and input into the development of the new operation now and as it is established. LMEs have been conducting meetings with those receiving services and those currently providing services to discuss the changes and I hope you have been able to participate in those and in subsequent such meetings. Some of these forums have been conducted by the Jordan Institute for Families of the University of North Carolina School of Social Work under the direction of Professor Gary Nelson with a particular focus on the outcomes we hope to achieve with this system as they effect persons with disabilities and their families. The Department of Health and Human Services has recently established a Waiver Advisory Council http://www.ncdhhs.gov/mhddsas/providers/1915bcWaiver/index.htm comprised of stakeholders for the purpose of obtaining advice and council on the development of this new system. These meetings are open to the public and I would encourage you to attend and participate. There is an abundance of information about the B-C Waiver implementation on this website and you may want to take a look at the Strategic Plan listed there.

As we discussed, this is a significant change for the state of NC but a change that was deemed necessary by both the Department of Health and Human Services and by vote of the NC General Assembly. Transitions of this kind are necessarily disconcerting. While it is understandable that many individuals who have received services in the current system and some who have delivered those services would like the system to continue under its present structure, the decision was made that this is just not feasible. There are long waiting lists for service, some providers have not been of highest quality , some individuals and families have had to endure a revolving door of service providers with no reliability or consistency in service delivery, research has demonstrated that there is currently no relationship to the intensity of need of those who receive services and the services they receive. Some with relatively low need receive the highest cost services while many with very high need receive no services at all. In these lean budget times and with the pending changes in federal health care set to go into place in 2014, it is critical for the General Assembly, in concert with the DHHS and stakeholders to develop an accessible system that is of highest quality, responsive to the needs of people with IDD, MI, SA and their families and well managed to assure that both federal and state dollars are fairly and equitably allocated to the best benefit of the diverse population in need of services. Accountability is built in at every step with both internal and external evaluation of both program outcomes and expenditures. The General Assembly is committed to the development of this system with the meaningful input of individuals with disabilities and their families and with a foundation in evidence based outcomes. Your input and that of other key stakeholders is vital in assuring that the system achieves these intended goals.

I hope I was helpful as I answered your specific questions about the implementation of the B-C Waiver and its potential impact on services for your daughter and other people with IDD in our state. You suggested that you would like to develop a list of additional questions that we could discuss in a face-to-face meeting and I am happy to do that. Please let me know when you would like to schedule that meeting.

I look forward to speaking with you again.


Pat Porter

Patricia Porter, PhD, Consultant  

Health and Human Services 

North Carolina General Assembly
301-B Legislative Office Building
300 N. Salisbury Street
Raleigh, NC 27603
(919) 301-1982