In a Medicaid waiver certain standard Medicaid requirements are “waived.” The provider network can be “right sized” to help ensure high-quality, financially-stable providers chosen by their ability to meet the needs of the community. Savings in the system can be reinvested in additional services. There is greater control of reimbursement rates for services to respond to local needs and the opportunity to create fiscal incentives to providers that can generate improved consumer outcomes.
At that time Alliance began operating as a Managed Care Organization (MCO) for mental health, intellectual/developmental disability (I/DD) and substance abuse services. As an MCO, Alliance has greater flexibility to shape the service delivery system to ensure access to quality care that results in better consumer outcomes.
Alliance manages those dollars as well, creating uniform authorization management of Medicaid and State-funded services and a single point of accountability for all public funding.
LME stands for Local Management Entity, which is an agency of local government – area authorities or county programs – responsible for managing, coordinating, facilitating and monitoring the provision of mental health, intellectual/development disability and substance abuse services. Alliance continues to operate as an LME for Durham, Wake and Cumberland counties under contract with the NC Department of Human Services in addition to its MCO operations.
Alliance works with the Johnston Area Authority to manage behavioral health and I/DD services for citizens of Johnston County. Johnston has a contract with Alliance to perform certain functions of the Managed Care Organization.
The waivers result in stable and predictable Medicaid costs. MCOs are paid a determined amount of money each month for each Medicaid consumer and have the responsibility to manage care with that pool of money. A goal of managed care is to improve the quality of care while controlling the rate of Medicaid growth and managing care for high-risk/high-cost individuals.
Goals of the Medicaid waiver are to:
-Provide consumers with consistent access to high-quality services in the community
-Use resources in a fair and consistent manner to achieve positive outcomes for consumers
-Provide all services that are in the Medicaid benefit plan available to consumers, so their medically-necessary needs can be met.
Waivers help enable Alliance to “right size” the provider network to better ensure high-quality, financially-stable providers chosen by their ability to meet the needs of the community. Provider credentials are carefully verified and they closely monitored for quality and consumer satisfaction.
The utilization management function of the MCO provides a powerful tool to help ensure that consumers receive the right service at the right level, and Care Managers are available to provide direct support to high-cost/high-risk consumers. Alliance has the resources to enhance its focus on consumer-driven care through the expansion of best practices such as recovery, self-direction, System of Care and person-centered planning that use peer support and consumer-led models of care. Waivers provide a strong mandate for Alliance to continue its ongoing efforts to integrate behavioral health and intellectual/developmental disability care with the primary health care system, ensuring more comprehensive care for consumers.
Alliance works to ensure consumer choice, to provide local responsiveness to individualized consumer needs and direct relationship with care providers, to give voice to consumers, family members and advocates, to provide 24/7 phone access and crisis services, and to support local CFAC activities.
Alliance is staffed with I/DD expertise and qualified I/DD professionals across all departments who are committed to addressing the unique concerns that parents and guardians of individuals with I/DD share. Additionally, the Alliance CFAC (Consumer and Family Advisory Committee) includes parents and guardians who can speak from the I/DD perspective when advising Alliance on practices and decisions that impact services and supports available to individuals with I/DD.
Alliance I/DD Care Coordination is designed to provide consistent and effective support to those on the NC Innovations Waiver and to those who meet certain criteria who are in need of assistance connecting to and accessing available resources and supports.
All individuals previously with the CAP MR/DD Waiver were transitioned to the Innovations Waiver without exception. A direct crosswalk of services from the CAP MR/DD Waiver to the Innovations Waiver was designed to ensure no break in service when the Innovations Waiver took effect on February 1, 2013.
Every individual who transitioned from CAP-I/DD to the Innovations Waiver has an assigned I/DD Care Coordinator who works for Alliance. That Care Coordinator will do some, but not all, of the functions previously carried out by Targeted Case Management. A new service called Community Guide may be useful in addressing the needs of the individual that previously were covered by Targeted Case Management. Care Coordinators, service providers (including current I/DD TCMs), and advocates have worked with individuals and their families to ensure that the transition away from Targeted Case Management to other supports, including Care Coordination and Community Guide, was as smooth as possible.
For individuals who previously received non-CAP MR/DD Targeted Case Management (via Medicaid or State IPRS funding), transition plans were developed by each Person Centered Planning Team to address how each individual’s needs would continue to be addressed once Targeted Case Management was no longer an option on the State plan for services. Training was provided to Targeted Case Managers and direct service providers about options for those who were losing Targeted Case Management. These include maximizing reliance on natural supports, direct service providers becoming Lead Agency, utilizing new B3 Services (Respite and Community Guide) and, when certain criteria are met, assigning an Alliance I/DD Care Coordinator to assist.
Over time Alliance will most likely have a smaller network which adheres to all access standards and better allows for provider collaboration, ensures the health of the provider network, and allows for increased oversight and fiscal management by the MCO. In this way, enrollees are assured of appropriate provider choice while providers in the network have an enhanced opportunity for economic viability in the marketplace.
Initially, all providers with existing contracts with The Durham Center and Wake LME and those providing services to Medicaid-funded clients with Medicaid based in the Durham-Wake coverage area were entitled to apply for membership to the network and participate in a credentialing process. Alliance will conduct an annual capacity and geo-access study to evaluate the capacity of the enrolled and credentialed provider network to meet the needs of the coverage area and to measure geographic access to provider locations. These studies will help Alliance know when to add or limit capacity.
Credentialing is a process of review to approve a practitioner who applies to participate in an MCO. Specific criteria that comply with regulatory and State statutes are used in the process of determining initial and ongoing approval for participation.
For the first year, all current providers and practitioners were invited to join the Provider Network through the credentialing process. This was designed to prevent disruption in services for consumers and to provide the opportunity for transition to the MCO environment.
The provider agency will determine the number of staff members required to provide services, which is largely a business decision on the part of that provider agency. Alliance will determine the number of provider agencies required to meet the needs of enrollees based on access standards and its geo-access and accessibility studies.
Provisionally or newly-licensed professionals may join a provider agency, hospital system, etc. where they will practice under the supervision of the appropriate licensed staff. New contracts will be issued based on Alliance access standards and its geo-access and accessibility studies. Alliance is working closely with all state licensure boards.
No. The MCO will conduct an annual capacity and geo-access study to evaluate the capacity of the enrolled and credentialed provider network to meet the needs of the coverage area and to measure geographic access to provider locations. These studies will help the MCO know when to add or limit capacity. (See question: “How will local providers be affected?”)