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HomeMy WebLinkAboutAgenda - 05-17-2011- 5uORANGE COUNTY BOARD OF COMMISSIONERS ACTION AGENDA ITEM ABSTRACT Meeting Date: May 17, 2011 Action Agenda Item No. J - U SUBJECT: OPC Area Program -Partnership Proposed with Piedmont Behavioral Health LME (Medicaid Waiver Expansion) DEPARTMENT: County Manager's Office PUBLIC HEARING: (Y/N) No ATTACHMENT(S): A. Update Summary B. Frequently Asked Questions C. Public Information Efforts INFORMATION CONTACT Gwen Harvey, Asst Co. Mgr, 245 -2307 Judy Truitt, OPC/LME Director, 913-4037 PURPOSE: To authorize the Orange-Person-Chatham (OPC) Local Management Entity (LME) to undertake formal merger negotiations with Piedmont Behavioral Health according to State policies and statutes regarding 1915 (b) (c) Medicaid waiver expansion. BACKGROUND: OPC is the local governmental agency with responsibility for oversight and management of publicly-funded mental health, developmental disability, and substance abuse services in Orange, Person and Chatham counties. OPC provides screening, triage and referral for individuals needing services in the area; recruits and monitors an array of community service providers; and manages the distribution of state monies for services to consumers. OPC is governed by an Area Board comprised of one county commissioner from each of the three counties and the three county commissions appointing remaining board members, which exercises the powers and duties conferred by the North Carolina General Assembly. OPC was approached in February 2010 by Piedmont Behavioral Health (PBH), the LME currently operating under a successful 1915 (b) (c) Medicaid waiver pilot project, about the possibility of forming an alliance. PBH currently serves Cabarrus, Davidson, Rowan, Stanly, and Union counties. The Medicaid waiver is an agreement between the state and the Center for Medicaid Services to be released from certain Medicaid rules. Waivers are used to improve access to and quality of services and manage costs. Preliminary negotiations for an OPC-PBH alliance were authorized, commenced, and paused while sanction for LME waiver expansion gained support in the General Assembly. On March 31, 2011 the Department of Health and Human Services (DHHS) issued its final Request for Applications (RFA) to allow statewide Medicaid waiver expansion under the model created by 2 PBH. Applications must be received by May 20 2011. Following continued assessment by OPC management with extensive discussion by the OPC Board, the vote was unanimous to seek authorization from the three boards of county commissioners to re-engage in negotiations to merge with PBH. On April 18, 2011 the Person County Board of Commissioners and the Chatham County Board of Commissioners each reviewed and approved the OPC Board recommendation to pursue negotiations to merge with PBH. The Orange County Board of Commissioners received an updated report from OPC LME Director Judy Truitt in work session on May 10th. Ms. Truitt provided a summary of events and responded to questions. Note that OPC, along with the Five County and Alamance-Caswell LMEs are each petitioning the State to merge with PBH. Their addition, if approved by their boards of county commissioners and subsequently the State, would enable PBH to encompass a total population of 1,390,224, with 193,391 Medicaid eligible individuals (3 years of age and older). Below is the specific breakdown of each county within the proposed expansion of PBH: PBH member counties: Cabarrus, Davidson, Rowan, Stanly & Union Total population: 744,402 (including birth to 3) 714,749 (excluding birth to 3) Medicaid eligible individuals: 96,558 (excluding birth to 3) Five County member counties: Vance, Franklin, Warren, Granville & Halifax Total population: 236,449 (including birth to 3) 227,760 (excluding birth to 3) Medicaid eligible individuals: 48,831 (excluding birth to 3) Alamance Caswell member counties: Alamance & Caswell Total population: 173,713 (including birth to 3) 167,138 (excluding birth to 3) Medicaid eligible individuals: 25,630 (excluding birth to 3) OPC member counties: Orange, Person & Chatham Total population: 235,660 (including birth to 3) 227,963 (excluding birth to 3) Medicaid eligible individuals: 22,372 (excluding birth to 3) Attachment A provides a summary update from OPC including DHHS parameters guiding waiver expansion and working partnerships. Attachment B is a Frequently Asked Questions document on the possibility of OPC joining PBH. Attachment C outlines additional steps underway by OPC to inform and involve consumers, families and community at-large on merger potential FINANCIAL IMPACT: There is no financial impact associated with authorizing formal merger negotiations between OPC and PBH. RECOMMENDATION(S): The Manager recommends the Board authorize merger negotiations between OPC and PBH in accordance with State sanctioned 1915 (b) (c) Medicaid waiver expansion. A$cc~+.,~.~-~ SUBJECT: OPC Area Program Update -April 2011 PURPOSE: To receive a report on the expansion of the 1915(b)(c) Medicaid waiver & the expected impact on the mental health, developmental disabilities & substance abuse service system in Orange, Person & Chatham Counties. BACKGROUND: On March 31, 2011 the Department of Health 8~ Human Services (DHHS) released an RFA for the expansion of the 1915(b)(c) Medicaid waiver, which will have significant impact on the organizational structure and governance of the existing system. HISTORICAL INFORMATION: House Bill 381, passed in October 2001, outlined a major transformation of the public mental health system. Guiding principles included: • Greater choice for consumers • No wrong door for admission to services • Services provided in the local communities • Greater involvement by both consumers and the provider community • State wide standardization and accountability • Focused shift to best practice and evidence-based treatment • Separation of management oversight from the provision of service In response to the new legislation OPC initiated divestiture of service programs in December 2003 and began its transition to a Local Management Entity (LME) with responsibility for: • screening, triage & referral for consumers entering the service system; • authorization of all state and/or locally funded services; • endorsement and monitoring of a comprehensive provider network; • customer service and community planning for our three county region. In 2007 the North Carolina General Assembly passed legislation that required that LMEs have a total population of 200,000+ or cover a geographic region of six or more counties. With a total population of 227,963 OPC is the fourth smallest LME in the state. As noted above LMEs were given responsibility for management of state and locally funded services, while management of Medicaid funded services was given to Value Options, a private for-profit vendor. This remained true until April 2005 when DHHS began operating a pilot project which allowed Medicaid funded services for mental health, developmental disabilities and substance abuse treatment to be provided on a capitation basis through a 1915(b)(c) combination waiver at PBH, the LME which covers Cabarrus, Davidson, Rowan, Stanly ~ Union counties. This pilot project has been successful and DHHS has made the decision to move forward with statewide expansion of the 1915(b)(c) waiver. What is a 1915(b)(c) Medicaid waiver? In 1965 amendments to the Social Security Act (SSA) established the Medicaid program. Under the Medicaid program each state establishes its own eligibility standards, benefits packages, payment rates, and program administration. The Social Security Act authorizes multiple waiver and demonstration authorities which allows for flexibility at the state level. Under Section 1915 (b) of the SSA, waivers are granted which allow states to implement managed care delivery systems and restrict consumer choice of providers. These specific waivers often target individuals with mental health and substance abuse issues, although some services are 3 4 available for people with intellectual/developmental disabilities (I/DD). States may choose to simultaneously operate 1915 (b) and (c) waivers. Medicaid waivers are used to improve access to and quality of services, as well as manage cost. REQUEST FOR APPLICATIONS -1915(b)(c) Medicaid Waiver Expansion KEY POINTS: • This is the final RFA that will be issued for statewide expansion. • Full expansion is expected to be completed by January 2013. • LMEs applying to operate a waiver must have an unduplicated minimum Medicaid eligible population of 70,000 individuals 3 years and older; a total population size of 300,000 by July 2012, and a total population size of 500,000 by July 2013. [OPC =total population of 227,963; number of Medicaid eligible individuals 3 years and older is 22,372] • A single LME may apply if it meets all minimum requirements. If a single LME does not all minimum requirements it will be expected to merge with one or more other LMEs, with one entity being identified as the lead LME. • Applications must be received by May 20, 2011. • By the date of the RFA application submission, all LMEs must identify which lead LME they will partner with to pertorm the required Medicaid managed care and LME functions. If LMEs do not identify working partners, then DHHS will assign LME catchment areas. OPTIONS AVAILABLE TO OPC: In February 2010 OPC was approached by PBH, the LME currently operating the 1915(b)(c) pilot project, about the possibility of forming an alliance. With approval of the OPC Area Board negotiations were initiated. In June 2010 legislation was passed which restricted PBH from expanding their geographic region and limited the number of sites for expansion of the Medicaid waiver. OPC's negotiations with PBH were put on hold. Legislative support now exists for removal of the restrictions on PBH, as well as expansion of the waiver, and the OPC Area Board has authorized the Area Director to re-engage in negotiations. OPC AREA BOARD RECOMMENDATION TO BOCC: At their April 11~' meeting the OPC Area Board reviewed the RFA and after extensive discussion the following motion was approved by unanimous vote. The OPC Area Board authorizes management of OPC to pursue negotiations with PBH to be identified as the lead LME to operate Medicaid funded services through a 1915 (b)(c) combo waiver for the OPC catchment area; to pursue a merger arrangement with PBH for the provision of services in the Orange, Person and Chatham counties catchment area; and to seek authorization of the Boards of Commissioners of Orange, Person & Chatham counties to proceed with negotiations with PBH towards these ends. Because Chapter 122C of the North Carolina General Statutes empowers and requires counties to determine the area authority through which they provide services, the OPC Area Board requests authorization from each county to proceed in accordance with the motion it adopted. Successful negotiations would result in the necessity at a later date of a resolution from each Board of County Commissioners to both join PBH for the provision of services and to dissolve OPC. The only action needed at this time is the Board of County Commissioners' concurrence in the negotiations recommended by the OPC Area Board. OPC and Waiver Expansion Frequently Asked Questions 1. Is OPC merging with another LME (Local Management Entity)? OPC is currently talking to PBH about the possibility of joining them. At their regularly scheduled meeting on April 14th the OPC Area Board reviewed the Request for Application (RFA) that was recently released by the Department of Health 8~ Human Services (DHHS) related to the expansion of the 1915(b) (c) waiver. After extensive discussion the OPC Board voted unanimously to move forward in negotiations with PBH and to seek authorization from the Boards of Commissioners in Orange, Person 8~ Chatham counties to do so. 2. Who is PBH and why is OPC in discussions with them? PBH is an LME (ike OPC. They currently operate a Medicaid waiver and have asked us to partner with them. PBH is a Local Management Entity (LME) like OPC which covers Cabarrus, Davidson, Rowan, Stanly 8~ Union counties. In 2005 PBH was chosen to operate a pilot project which allowed Medicaid funded services for mental health, developmental disabilities and substance abuse treatment to be provided on a capitation basis through a 1915(b)(c) combination waiver. This pilot project has been successful and DHHS has made the decision to move forward with statewide expansion of the 1915(b)(c) waiver based on the model created by PBH. In February 2010 OPC was approached by PBH about the possibility of forming an alliance. With approval of the OPC Area Board negotiations were initiated. In June 2010 legislation was passed which restricted PBH from expanding their geographic region and limited the number of sites for expansion of the Medicaid waiver. OPC's negotiations with PBH were put on hold. Legislative support now exists for removal of the restrictions on PBH, as well as expansion of the waiver. 3. Why would OPC want to merge? 5 Under proposed legislation, OPC is currently not large enough to operate as we currently exist. 6 The number of LMEs in the state has been reduced over the years from 41 to 23. Given the current economic climate, LMEs have been encouraged to continue consolidation efforts in order to create efficiencies and savings. OPC is the fourth smallest LME in the state based on the population of our three counties (227,963), so with the recent release of the RFA and related legislation, it is no longer an option for OPC to remain "as is". The minimum population threshold for LMEs will be increased to 300,000 by 7/1/12 and 500,000 by 7/1/13, and the number of LMEs in the state will be reduced to 8-10. While we are very proud of OPC and its accomplishments over the last 40+ years, we recognize that we will need to change, and we have tried to be thoughtful and proactive in considering our future options. 4. Will OPC still exist? Yes, although we may look a little different in the future. We are currently in discussions with PBH about what the local presence in the OPC community will look like. OPC will most definitely still exist and will be available to respond to the needs of the local community, although our internal structure may look different than it does currently. 5. What is a waiver? A waiver is an agreement between the state and Center for Medicaid Services in Washington to be released from certain Medicaid rules. In 1965, amendments to the Social Security Act (SSA) established the Medicaid program. Under the Medicaid program each state establishes its own eligibility standards, benefits packages, payment rates, and program administration. There are two major types of serviced delivery systems in Medicaid; fee for service and managed care. States wishing to operate managed care service delivery systems must apply for a waiver of certain Medicaid rules. The Social Security Act authorizes multiple waiver and demonstration authorities which allows for flexibility at the state level. Under Section 1915 (b) of the SSA, waivers are granted which allow states to implement managed care delivery systems and restrict consumer choice of providers. These specific waivers often target individuals with mental health and substance abuse issues, although some services are available for people with intellectual/developmental disabilities (I/DD). Under Section 1915(c) of the SSA, waivers exist to provide a continuum of services in the community to individuals who are disabled. Presently North Carolina operates a 1915 (c) waiver for individuals with I/DD referred to as the CAP-MR/DD program. States may choose to simultaneously operate 1915 (b) and (c) waivers. 7 Medicaid waivers are used to improve access to and quality of services and manage cost. Entities that operate waivers are generally referred to as Managed Care Organizations (MCO). NC has chosen to operate its waiver through a single prepaid inpatient health plan (PIHP). PIHPs are managed care organizations that provide, arrange for or otherwise have the responsibility for the provision of specialty care (including inpatient and institutional) for individuals with MH/DD/SAS needs. PBH currently operates a PIHP and is the only combined 1915(b) (c) waiver in North Carolina. North Carolina has obtained approval from the Centers for Medicare and Medicaid Services (CMS) to transition the entire state to a combined 1915 (b) (c) waiver replicating the PBH model statewide. For more information about waivers, please see the waiver section on the OPC website, www.opcareaproaram.com 6. What does OPC think about managed care? We think it is the right thing to do. OPC supports the concept of managing care to assure that all individuals receive appropriate services, and we strongly support the concept of public management of the behavioral .healthcare system. 7. Why are some groups opposing the waiver? Some people are worried about what this change will mean for providers and consumers. Expanding the waiver statewide is a big change for North Carolina, and as with any change of this magnitude, there is some anxiety about what it all means. Some advocacy groups, particularly those representing the interests of individuals with I/DD, have been very vocal about their concerns for that population in a waiver environment. While it is true that care for these individuals (as well as individuals with mental health and substance use disorders) will be managed differently in the future, PBH, as well as other states, have successfully operated waivers that appropriately serve all disabilities. An article by the National Leadership Consortium on Developmental Disabilities that looked at the experiences of four states concludes... Smith and Ashbaugh, in a groundbreaking 1995 analysis of potential applications of managed care within the developmental disabilities services sector, wrote: "Whatever mistrust there might be about managed care has to be balanced against its trinity of promises: -ower costs, better access, and higher quality. Curbing Medicaid payments to the states means developmental disabilities systems will face a far different fiscal landscape in the foreseeable 8 future than has been true over the past decade. This altered (low growthj fiscal landscape has enormous implications for the health and vitality of these systems and even more profound implications for the people and families who depend on these systems for supports. In this vein, dismissing managed care makes no sense. DD service systems will need to take advantage of every tool available in order to survive and be responsive to the people they support." These words were written at a time when Congress appeared to be on the brink of imposing an across-the-board cap on federal Medicaid spending. Today, our nation is rapidly approaching another crisis in financing not only of Medicaid services but of other major social entitlement programs as well (e. g., Medicare; Social Security, SSI, Food Stamps, etc.J. Given the circumstances, Smith and Ashbaugh's admonition to consider all of the "arrows in our quiver" seems as relevant today as it was thirteen years ago. And, as unsettling as it may seem, managed care is one of those arrows. For access to the full article referenced above as well as information about waivers from several advocacy groups, please see the waiver section on the OPC website, www.oacarea proclram.com 8. What will happen to my (or my child's) services? In general, most services should remain the same, although who approves them will change. Expansion of the waiver should be a fairly seamless process for consumers. It should result in greater consistency across the state in the services that are provided, in how services are accessed, and in expectations and requirements for providers. If savings are realized, they can be put toward creative, innovative services that may not be typical Medicaid reimbursable services. The biggest change will be that Medicaid services will no longer be authorized by the state's current vendor, Value Options, but instead will be authorized by the LME. How case management is provided may also change for some consumers (see question # 12) 9. Will I be able to keep my same provider? As much as possible, OPC will work to help consumers keep their current provider if they so desire. As indicated in the 1915 (b) waiver amendment (http://www.ncdhhs.gov/mhddsas/waiver/2011 /section 1915-bwaiver- renewal l 1-13.pdf) "Enrollees will have free choice of providers within the prepaid inpatient health plan (PIHP) and may change providers as often 9 as desired. If an individual joins the PIHP and is already established with a provider who is not a member of the network, the PIHPs will make every effort to arrange for the consumer to continue with the same provider if the consumer so desires. In this case, the provider would be required to meet the same qualifications as other providers in the network. In addition, if an enrollee needs a specialized service that is not available through the network, the PIHP will arrange for the service to be provided outside the network if a qualified provider is available. Finally, except in certain situations, enrollees will be given the choice between at least two providers. Exceptions would involve institutional services or highly- specialized services which are usually available through only one facility or agency in the geographic area." 10. Under the waiver will OPC serve all the consumers that are currently being served without a cut in any services? We don't know. In addition to changes that will be created by the waiver, we also anticipate cuts to the rates paid for services. It is hard to say what impact those cuts will have on services. To answer yes to this question would assume that all current treatment plans match the needs of all individuals, which we do not believe has been proven to be the case when records have been audited. In a managed care environment you assess needs at the individual level and create treatment plans that are responsive to those needs within a very formal framework. To answer yes to this question would also assume that the resources currently available would remain so without change. As we are all well aware, North Carolina is facing a serious fiscal shortfall. We are expecting budget reductions at the administrative level and possibly at the service level. Medicaid 8~ Medicare rate reductions are already being rolled out, so the service system will likely face changes unrelated to implementation of the 1915(b) (c) waiver. 11. What will happen to OPC providers? As much as possible, OPC will work to keep our current provider network. One of the rules that is waived under a 1915(b) waiver is freedom of choice. That means waiver sites can have a closed provider network, limiting it to those providers with good outcomes. OPC has been fortunate to have a long-standing relationship with many excellent providers in our community, and that should not change. In fact, PBH has recommended to LMEs interested in becoming waiver sites that current providers be included when the waiver is opened in the LME's community. 10 If a provider then subsequently is not performing, they would be removed from the network. 12. Who is going to do case management? Based on the latest information we have received, it appears that LMEs will do care management and coordination. According to the latest waiver fact sheet published by the Division of MH/DD/SAS (http://www.ncdhhs.ctov/mhddsas/factsheets/ 1915bcwaiverddfactsheet4 -11.pdf), targeted case management will not be a stand-alone service for any disability group under the waiver. The functions of care management and coordination will be performed by the LME. However, individuals with Intellectual/Developmental Disabilities (I/DD) may receive a different type of direct service, called Community Guide, from provider agencies. 13. Will OPC have any type of forums to educate the community about what is going on? Absolutely. We are currently working on a strategic plan for educating the community about the waiver and will be publishing details as soon as we have them. 14. Are the counties going to be at risk if the waiver loses money? It is our understanding that the counties will not be at risk. In a waiver the "risk" (of losing money) is transferred from the state to the LME, which serves as a Managed Care Organization (MCO). The waiver requires the MCO to have an adequate risk reserve. Concerns have been expressed about the counties' responsibilities if the. LME overspends. It is our. understanding that the Institute of Government has researched this issue and provided information which would not support the assertion that the counties would be at risk in a waiver setting. Also, Secretary Cansler reported on April 5th that there was consideration being given to either new or revised legislation which would assure that counties would not be at "risk" in a waiver setting. 15. Will money be taken away from developmental disability services and given to mental health and substance abuse services? We have no reason to believe that this would happen. 11 We are aware that there is concern that developmental disability funding will be used to serve other disability areas in a waiver setting. We are also aware, however, that this is the same argument that was made when area authorities were shifted to a single stream funding model. We have no information to suggest that has ever occurred in a program with single stream funding; no evidence to suggest that it has occurred at PBH; and no reason to believe that it would occur in any new waiver site. 16. Where can I find more information about waivers? OPC has created a section on our webpage that contains links to resources as well as various documents that have been written about waivers. You can access our site at www.opcareaprogram.com 17. Who can I call if 1 have questions? If you have questions, you can contact OPC's customer service line at (888)277-2303 or (919)913-4120 or you may e-mail your questions directly to waiverquestions@opc-mhc.org We will be posting the questions and answers and will be updating this FAQ document on a regular basis. The Division of MH/DD/SAS is also responding to questions sent to: 1915BC.Waiver.Contact@dhhs.nc.gov ~~,~r,~ ~ From: Judy Truitt-. Sent: Tuesday, April 26, 2011 2:49 PM To: Steve Yuhasz; 'Lynn Ikenberry' (ikenbel@mindspring.com); 'Mary Cay Corr' (marycaycorr@mindspring.com); Mike Rosenthal (pmrmms@aol.com); jimmyb60@embargmail.com; 'Amandab' (amandab51 @charter.net); 'Rachel O.. Winstead' (Wnstead@Bennett.edu); 'Carol Mitchell' (msch48@esinc.net); Gentry, Bill (wgentry@unc.edu); Brian Bock (brian.bock@chathamnc.org); edwardsbrooks@earthlink.net; geogreg@chatham.k12.nc.us; Tom Glendenning (goaglen@embargmail.com); Heather Johnson (Chathambooks@gmail.com); john@levineandstewart.com; 'Heather Nash' (heathnash27@yahoo.com); vbeckt@aol.com Cc: .Frank Clifton; Gwen Harvey; hyork@personcounty.net; ghodges@personcounty.net; Charlie Horne (charlie.horne@chathamnc.org); Renee Paschal (renee.paschal@chathamnc.org); Inease@brownandbunch.com; Management Team Subject: OPC Update April 26, 2011 Attachments: Waiver FAQ.pdf Dear Board members & County partners, as a quick update please find the following information. • On April 18th the Person County Board of Commissioners reviewed and approved OPC moving forward in negotiations with PBH. • On April 18th the Chatham County Board of Commissioners reviewed and approved OPC moving forward in negotiations with PBH. • The Orange County Board of Commissioners has scheduled time on their May 10th and May 17th meeting agendas - I will present at both meetings. • On April 21St Debra Farrington and I met with the OPC Consumer & Family Advisory Committee (CFAC). The meeting went well and it is my understanding that CFAC is working on a letter of support, which will be ready early next week. On April 21St we uploaded a significant amount of information to the OPC webpage at www.opcareaprogram.com. Included would be: • A Question and Answer (Q&A) document with the questions that we have received thus far. I have attached a copy for your review - we will be updating this on a routine basis. • We also posted information regarding both PBH and Medicaid waivers in general - we will continue to add new information as it becomes available. Other planning efforts: We are planning to release a series of articles in local newspapers -several editors have already indicated that they are willing to work with us as to educate our consumers, families & communities. We are planning to hold public forums in each of our three counties beginning in mid-June. Finally, OPC staff participate on approximately 80+ committees/collaboratives/forums - we are developing formal talking points and will ask that staff members educate stakeholders as part of their participation with these groups. Please do not hesitate to let me know if you have any questions and as always thank you for your on-going support of our system. Judy 12 5/2/2011 13 Judy R. Truitt OPC Area Program 919-913-4010 Confidentiality Notice: This a-mail message including attachments, if any, is intended for the use ofi the individual or entity to which it is addressed. This message may contain information that is privileged, proprietary, confidential and exempt from disclosure. If you are not the intended recipient, you are notified that any dissemination, distribution or copying of this communication is strfcNy prohibited. !f you have received Phis message in error, please notify the sender and erase this message immediately. Password protected attachmen#s to this a-mail message may contain information concerning a consumer receiving or referred to alcohol/drug abuse treatment that is being disclosed with the consent of the consumer. This information has been disclosed to you from records protected by Federal confrdentiality rules (42 CFR Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disc/osure is expressly permitted by the written consent of the person fo whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. 5/2/2011