CAP-IDD ... this is NOT NC Innovations

From Mary K. Short:

The links to the announcements and guidance are below.  The changes from CAP-MR/DD to CAP-IDD are approved by CMS on 10/1/2012 BUT are not implemented until 1/1/2013.  If you are in an LME that is supposed to convert to an MCO before or on 1/1/2013 THIS DOES NOT APPLY TO YOU (or if you are already on the NC Innovations waiver) because you should be working on the transition to the NC Innovations waiver for your LME/MCO "go live" date prior to or on 1/1/2013.  The Special Medicaid Bulletin is specific about timelines and who is and who is not impacted.

Additionally, this is part of what Doug Sea sent out to providers/case managers.  I know he works with DRNC (Disability Rights North Carolina www.disabilityrightsnc.org) and you should probably contact them if you have questions.  If you are in Legal Services of the Southern Piedmont area (Mecklenburg & surrounding), then contact LSSP at www.lssp.org.

The instructions do not include the right to request continuation of current services as a reasonable accommodation under the ADA. Nor do the instructions provide for the right to a notice with appeal rights if such a request is made and denied. It will be up to advocates and providers to let families know they have the right to submit such a plan and to appeal to OAH if denied if they are at serious risk of institutionalization without continuation of their current services. Please make families aware of this.  

Essentially the same issue will occur for families transitioning to the Innovations waiver on January 1 .  Those 36 counties are also listed in this bulletin.

Here are some other possible specific issues to look for as CAP-DD families transition to the new CAP-IDD waiver (for a short time) and to the Innovations waiver:

A.      if LME doesn’t have adequate provider network, can family continue to be paid to provide home support services?

B.      If rate paid to provider is changing (eg no more enhanced personal care services or enhanced respite) and new rate is inadequate to attract qualified provider for this recipient, can recipient appeal rate reduction/loss of enhanced service?

C.      Does the requirement that  Intensive In home support have a fading plan and the 6 month limit for intensive night services violate the ADA or EPSDT?

D.      Does the restriction on services during school hours violate EPSDT if the child requests personal care (not hab serv) in excess of that limit?

E.       Does child recipient have right to case management in addition to care coordination under epsdt if medically necessary in that case because the LME staff are not adequately trained or don’t do medically necessary work the current case manager has been doing?

F.       Does the LME violate due process by “crosswalking” to new services without explaining right to request continued current service and to appeal if denied?

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

Special Medicaid Bulletin:

http://www.ncdhhs.gov/dma/  (SCROLL down, it's the first bullet point on the left.)

OR direct link to the Bulletin:

http://www.ncdhhs.gov/dma/bulletin/pdfbulletin/1012_Special%20Bulletin_IDD_Waiver.pdf

CLINICAL POLICY 8M:

http://www.ncdhhs.gov/dma/mp/index.htm 

(Clinical Policy 8M ... this is the IDD 8M.  I do not have an answer for how it got approved and posted without an additional comment period!)

Parent Guest Contributor: Anna Cunningham

There's a lot going in North Carolina regarding the statewide 1915(b)(c) Medicaid Waiver and CAP I/DD / mental health reform / overhaul... more than any one person (be it parent or professional, or I dare say, legislative member) can keep up with. 

As a short-staffed working mother of a DD teenager and new "typically developing" kindergartener, I often find it difficult to keep up with posting even the basic important stuff between "regular life" and "special life"...

I mean, as working parents of school-age children, we all know what it's like running the rat-race juggling our routine responsibilities, meet deadlines, pay bills, grocery shop, squeeze in the occasional doctor or hair appointment, and lug our kids around to various activities, play dates and so on... I do all that too.

But to put things in perspective for those working parents fortunate enough not to have to deal with the struggles and challenges of caring for and protecting a child (or adult) with Intellectual Disabilities, here's a breakdown of my extra "special" obligations so far for this calendar year:

• 1 three-day hospitalization,
• 22 (usually day-long)  medical appointments with doctors and specialists (to include: dental, endocrinology, behavioral, neurology, gastroenterology, ophthalmology, orthopedics, medical rehabilitation, and physical therapy),
• 2 (2+ hour) IEP's (last calendar year there were 5 or 6),
• 3 CAP-related meetings (not including countless phone calls), and
• 5 other special DD involved events, meetings, and happenings.

Those are just the appointments and meetings specially relating to the specialized care, well-being and education of my daughter and does not include sick days, Miracle League baseball games, legislative assemblies, meetings with Senators and Representatives, DWAC meetings, other advocacy meetings and rallys, nor does it include any of what most of us would consider "routine" responsibilities as a grown-up and a parent, such as extra-curricular activities and appointments for my "typical" child, nor for myself (as if I had time for me)...

Which is why I've frequently been asked, "When do you sleep?!" Well, I don't, much.

That's just how we special parents roll. 

But because the future of our children and their peers during this transition period is so vitally important and there's a great deal of important information to get out, explain, break down, dispel, and share with others, I've invited fellow Special Mother and Advocate, Anna Cunningham, to join in the blogging fun.

It's not uncommon when I'm out banging cans and preaching my cause to be asked if I know Anna or for someone wanting to connect us... I mentioned that to Anna when we spoke regarding sharing the voice of the World Wide Web; she laughed and said the same thing happens to her about me. ;-)

More about Anna...

Leg. Correspondence, CMS, US HHS & Reports

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: Bev.Perdue@nc.gov, Thom.Tillis@ncleg.net, Phil.Berger@ncleg.net
CC: MaryKShort@aol.com, louis.pate@ncleg.net, justin.burr@ncleg.net, nelson.dollar@ncleg.net, martha.alexander@ncleg.net, william.brisson@ncleg.net, bill.current@ncleg.net, mark.hollo@ncleg.net, pat.hurley@ncleg.net, bert.jones@ncleg.net, marian.mclawhorn@ncleg.net, tom.murry@ncleg.net, fred.steen@ncleg.net, austin.allran@ncleg.net, doug.berger@ncleg.net, stan.bingham@ncleg.net, harris.blake@ncleg.net, jim.davis@ncleg.net, fletcher.hartsell@ncleg.net, eric.mansfield@ncleg.net, martin.nesbitt@ncleg.net, william.purcell@ncleg.net, tommy.tucker@ncleg.net, james.forrester@ncleg.net, andrew.brock@ncleg.net, ralph.hise@ncleg.net, marilyn.avila@ncleg.net, rayne.brown@ncleg.net, tricia.cotham@ncleg.net, beverly.earle@ncleg.net, shirley.randleman@ncleg.net, mitchell.setzer@ncleg.net
Sent: 6/25/2012 11:06:27 A.M. Eastern Daylight Time
Subj: Delay NC Innovations Expansion - URGENT

Dear Gov. Perdue, Speaker Tillis, President Pro Tempore Berger, and ladies and gentlemen of the NCGA:

I have tried over and over again to inform you of the urgent concerns I have had about DHHS/DMA/DMHDDSAS (the Department and its Divisions) in regards to the Medicaid 1915(c) waivers for the IDD/MR/DD/Autism population. I have tried to inform you of my urgent concerns regarding the role of CMS in approving waivers that were in violation of any number of federal statutes beyond CMS's own regulations, particularly the ADA and Olmstead.

On June 12, 2012, the Office of the Inspector General of the U.S. Department of Health & Human Services issued a report entitled, "Oversight of Quality of Care in Medicaid Home and Community Based Services Waiver Programs." I have provided the link to that report and copied the summary posted to the OIG.HHS.GOV web page below. Please see in particular the text I have highlighted in red/underline/bold.

I am once again asking you to stop the further implementation of the NC Innovations waiver. The fact that too much money has already been spent on the ADMINSTRATIVE components of implementation, is no justification for continuing the implementation. None of the LME/MCO's that have already transitioned have been adequately prepared. The absolute proof is NOT whether any one beneficiary has been institutionalized since their transition, but rather, the fact that none of the LME/MCO's is negotiating "enhanced" rates with providers for those beneficiaries who had been receiving CAP-MR/DD Enhanced services. Those Enhanced services are not available in the NC Innovations waiver.

Appendix J: Cost Neutrality Demonstration of the CAP-MR/DD Comprehensive Waiver (CMS NC 0662.R00.02 Jul 01, 2010): d. Estimate of Factor D. i. Non-Concurrent Waiver (chart). This document lists: Enhanced Personal Care Services # Users 366; Respite Nursing LPN # Users 37; Respite Nursing RN # Users 41; and Enhanced Respite Care # Users 415.

PBH, Pam Shipman, stood before the DWAC on Wednesday, June 20, 2012 and said that only 4 persons had a reduction/denial in services due to the transition: "No denials except for 4 requests for services or items not allowed under Innovations." [Link to document: (see page 11) http://www.ncdhhs.gov/mhddsas/providers/1915bcwaiver/dwac/6-20-12/pbh-presentation6-20-12.pdf.]

Please, delay the further implementation of the NC Innovations waiver.

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

http://oig.hhs.gov/oei/reports/oei-02-08-00170.asp
Report (OEI-02-08-00170)

06-21-2012
Oversight of Quality of Care in Medicaid Home and Community Based Services Waiver Programs

Complete Report

Download the complete report: http://oig.hhs.gov/oei/reports/oei-02-08-00170.pdf

Summary
WHY WE DID THIS STUDY

In recent years, States have altered their approach to providing Medicaid-funded long-term care services. Rather than providing the majority of that care in institutions-such as nursing homes-States are now providing more care in homes and other community-based settings. States most often provide this care through 1915(c) home and community-based services (HCBS) waiver programs, and the individuals served by these programs are most commonly disabled and/or over age 65. In fiscal year 2010, Medicaid expenditures for HCBS waiver programs serving this population totaled an estimated $8.9 billion. Strong oversight of waiver programs is critical to ensuring the quality of care provided to HCBS beneficiaries. The beneficiaries who rely on HCBS waiver programs are among Medicaid's most vulnerable, and the nature of these programs puts beneficiaries at particular risk of receiving inadequate care.

HOW WE DID THIS STUDY

States must operate their HCBS waiver programs in accordance with certain "assurances," including three assurances related to quality of care. To meet these assurances, States must demonstrate that they have systems to effectively monitor the adequacy of service plans, the qualifications of providers, and the health and welfare of beneficiaries. We based this study on a review of documents from CMS's most recent quality review of waiver programs from 25 States, as well as information gathered from structured interviews with staff from the 10 CMS regional offices.

WHAT WE FOUND

Seven of the twenty-five States that we reviewed did not have adequate systems to ensure the quality of care provided to beneficiaries. Although CMS renewed the waiver programs in all seven of these States, three did not adequately correct identified problems. Not only did these States fail to correct these problems before renewal of their programs, they also had still not adequately addressed the problems long after renewal. In addition, CMS did not consistently use the few tools it has to ensure that States correct problems related to quality of care.

WHAT WE RECOMMEND

We recommend that CMS: (1) provide additional guidance to States to help ensure that they meet the assurances, (2) require States that do not meet one or more assurances to develop corrective action plans, (3) require at least one onsite visit before a waiver program is renewed and develop detailed protocols for such visits, (4) develop a broader array of approaches to ensure compliance with each of the assurances, and (5) make information about State compliance with the assurances available to the public. CMS concurred with four of the recommendations and partially concurred with our recommendation to require onsite visits.