July 2023: Climbing the Same Mountain Together

Sarah Pfau, JD, MPH,
Senior Consultant
CCR Consulting

Policy updates as of July 26, 2023

NC DHHS Announces Plans to Launch Medicaid Expansion on 10/1/2023

• State Takes Action To Start Medicaid Expansion Oct. 1; Launch depends on General Assembly acting by Sept. 1 | NCDHHS

NC Medicaid and DMH/DD/SAS Clinical Coverage Policy Updates

Proposed State-Funded Service Definition Policies

All policies will be posted from 7/7/2023 – 8/5/2023

Send comments to: DMHIDDContact@dhhs.nc.gov

• State-Funded Community Living and Support
• State-Funded Day Supports Service Definition
• State-Funded Residential Supports IDD Service Definition
• State-Funded Supported Employment Service Definition
• State-Funded Supported Living Periodic IDD and TBI Service Definition

Two additional 1915(i) State Plan Option policies are posted from 7/14 – 8/28. 

Submit comments to medicaid.public.comment@dhhs.nc.gov.

• 8H-1: NC Medicaid: Supported Employment for IDD and TBI, 8H-1. (ncdhhs.gov)
• 8H-5: NC Medicaid: Community Living and Supports, 8H-5. (ncdhhs.gov)

The federal Centers for Medicare and Medicaid Services (CMS) approved the North Carolina 1915(i) State Plan Option effective 7/1/23 and below is the Medicaid Bulletin announcing that approval.

• NC Medicaid Obtains Approval of the 1915(i) State Plan Amendment | NC Medicaid (ncdhhs.gov)

NC Medicaid State Plan Amendment Updates

The Division of Health Benefits has posted numerous proposed NC Medicaid State Plan Amendments (SPAs) on this Web page:  2023 Proposed Public Notices | NC Medicaid (ncdhhs.gov).  Please see below for brief summaries of each SPA: 

• 23-0023:  Implement a future Clinical Coverage Policy 8D-4 (not yet promulgated) for ASAM-compliant, 1115 SUD Waiver 24-hour services for individuals with both a TBI and an SUD. 
• 23-0025:  Eff. 7/1/2023, increase Direct Care Worker PCS rates, including for CAP/C and CAP/DA, to $6.25/15 min. ($25/hr.) and that rate will include previous EVV rate enhancements.
  • NOTE:  This rate increase is contingent on “. . . legislative approval of appropriations sufficient to support the increase.”
  • *SEE ALSO below a 7/3/2023 DHB bulletin.  It includes information about PCS rates. However, the PCS section doesn’t state what the actual rates are effective 7/1 – 7/31 and the bulletin indicates that DHB is still in the process of updating the fee schedules. . .
• 23-0026:  Eff. 7/1/2023, implement a uniform add-on of $37.74 to Skilled Nursing Facility rates.
  • NOTE:  This rate increase is contingent on “. . . legislative approval of appropriations sufficient to support the increase.”
• 23-0027:  Eff. 7/1/2023, increase Private Duty Nursing rates from $45 to $52 / hr.
  • NOTE:  This rate increase is contingent on “. . . legislative approval of appropriations sufficient to support the increase.”

Related July 3, 2023 DHB Rates Bulletin

Consistent with the end of the federal COVID-19 Public Health Emergency, NC Medicaid is ending all* temporary COVID-19 rate increases and/or uniform adjustments included in rates through June 30, 2023, for the specific Medicaid services identified in SPECIAL BULLETIN COVID-19 #267: Temporary COVID-19 Rate Increases Ending June 30, 2023.

To maintain access to care for Medicaid members by supporting Medicaid providers whose temporary COVID-19 rate increases are ending while the General Assembly continues budget deliberations, NC Medicaid is implementing new temporary/interim rate increases, effective July 1, 2023,** through July 31, 2023, that estimate the permanent rate increases anticipated to be adopted by the General Assembly. As July 31 approaches, if a State budget has not yet been finalized, NC Medicaid will evaluate whether it is feasible to extend the new temporary/interim increases at some level.

Once a State budget has been finalized, NC Medicaid will implement any permanent increases at the levels appropriated in the budget and intends to systematically reprocess claims (or direct managed care organizations to reprocess claims, as applicable) retroactive to July 1 to adjust payments to the level of the appropriated permanent increases. This reprocessing will ensure that providers receive the full value of the legislated increases.

For more information, please see SPECIAL BULLETIN COVID-19 #267: Temporary COVID-19 Rate Increases Ending June 30, 2023. 

Samantha R. et al. v. North Carolina Department of Health and Human Services Updates

In November of 2022, in relation to a 2017 Disability Rights North Carolina lawsuit, Samantha R., et al. v North Carolina and the NC Department of Health and Human Services, an NC Superior Court judge filed an Order requiring NC DHHS to: 

1) Divert and transition individuals from institutionalization;

2) Increase access to Home- and Community-based Services via reductions in the Registry of Unmet Needs waiting list for the North Carolina 1915(c) Innovations Waiver;

3) Address the Direct Support Professional workforce deficit; and

4) Implement quarterly progress reporting to the Court. 

• In February of 2023, the same judge granted an NC DHHS motion for a stay of the Order while the lawsuit appeal is pending in the NC Court of Appeals.
• In May of 2023, Disability Rights North Carolina filed a Motion to Modify the November 2022 Order and remove a 2028 cessation date for new, long-term admissions to ICF-IID facilities. According to DRNC:  “The Motion asks the judge to change a provision of his November 2022 Order so that it does not apply to ICFs (except for the state-operated Developmental Centers). Specifically, the Order provides that new long-term admissions to certain settings would end in 2028, while allowing short-term admissions and respite. We filed the Motion because of community concerns that alternative community-based services would not be available in time for those who would prefer them, and that those who want to remain may lose the option to stay if their ICF closes, either because of the lack of long-term admissions or in anticipation of that prospect.”
• As of July 2023, the judge has not ruled on the May Motion.
• There is now an August 2, 3:15 p.m. Hearing on the May Motion scheduled in court. The hearing is being conducted via WebEx and is open to the public. The link to watch is here: https://nccourts.webex.com/meet/OrangeHistoricCR. 

In recent months, DRNC has been meeting with stakeholders including beneficiaries, guardians, and LME-MCOs to identify ways that people with I/DD living in ICFs can live in the highest quality, most integrated way possible.  Based on the focus group sessions, DRNC recommended the formation of a group for family members of people living in ICF settings. This group will not be affiliated with DRNC. Parent Carol Conway has agreed to organize and convene the group. If you are – or may be – interested, please reach out to Carol at carol.ann.conway@gmail.com. The group will decide for itself on a scope and direction. 

Upcoming Vaya Health LME/MCO Registry of Unmet Needs Training

• August 25, 9:00 – 10:30 a.m.
• During this free, virtual training, Vaya staff will provide an overview of the NC Innovations Waiver and the RUN, walk participants through the RUN application process, and explore the services available through the waiver. Register online.
• For more information, email training@vayahealth.com.

NC Medicaid Tailored Care Management Updates

• July 18, 2023: Updated List of Certified CMA and AMH+ Provider Entities
• July 14, 2023: Revised Tailored Care Management Provider Manual (83 pages)
• 5-page SUMMARY of July 14, 2023 Tailored Care Management Provider Manual Updates

Please see below for a bulleted list below that condenses the summary for you. 

 Updates include:

1. Revised policies for Acuity Tiers and Acuity-Based Contacts and Contact Monitoring [no acuity-based contact requirements apply]
2. Continuation of the use of a single (per member) Tailored Care Management rate of $269.66 through June 30, 2024, with an add-on of $78.94 for each Innovations and TBI waiver enrollee and member obtaining 1915(i) services.
3. Revised “glide path” dates for the percentage of provider-based versus plan-based TCM
4. Beneficiary eligibility for TCM by plan type (Medicaid Direct + LME/MCO) and community-based or residential services (ACT; ICF; SNF)
5. Clarification that until further notice, only LME/MCOs are eligible to provide TCM to Transition to Community Living (TCL) participants
6. Clarification regarding conflict-free care management:  Innovations and TBI Waiver and 1915(i) members may not receive TCM and services from the same provider entity. 
7. Clarification regarding LME/MCO data sharing requirements for patient risk lists and pharmacy lock-in
8. Effective 10/1/2023, LME/MCOs providing plan-based TCM to beneficiaries in Healthy Opportunities pilot regions will be eligible to use the pilot
9. Clarification regarding TCM entity assignment of care manager and supervising care manager for dually diagnosed members
10. Clarification that individuals with the equivalent of a high school diploma, such as a GED or certificate of completion, qualify to serve as care manager extenders as long as they meet other requirements
11. Authorizes Clinical Consultants to be licensed outside of North Carolina
12. Suggests plan- and provider-based TCM entities use Acuity Tier data to inform care manager assignments, make decisions about care manager needs, and generate risk stratification
13. Authorizes Care Extenders to gather information about a member’s progress towards goals identified in the care plan or ISP and share it with the care manager
14. Revised TCM staff training requirements
15. Revised Care Management Comprehensive Assessment policies 

North Carolina Behavior Analyst Licensure Updates

• The main website is:  ncbehavioranlystboard.org
• Reminder: Section 9K.3. of Session Law 2022-74 gave temporary authorization for Behavior Analysts to practice without the supervision of a licensed Psychologist while the NC Board was getting up and running.  Pursuant to Section 9K.3.(d), that temporary authorization expires 60 calendar days from July 13, 2023 (the first day that license applications became available). 
• See also Session Law 2021-22, which controls:
  • the licensure application process;
  • the licensure renewal process (every 2 years, with a license termination by operation of law if a Behavior Analyst does not renew within 60 days of the renewal date);
  • associated licensure fees ($250 new; $200 renewal unless or until the law is amended);
  • licensure reciprocity among States;
  • license suspensions and revocations and Behavior Analysts’ right to contested case hearings at OAH;
  • exemption from licensure for certain individuals (including family members as caregivers);
  • Behavior Analyst-client privilege / confidentiality parameters;
  • Behavior Analyst child abuse and neglect and adult with IDD abuse and neglect reporting requirements; and
  • NC Behavior Analyst Licensure Board composition, powers, and duties.

REMINDER:  Comment period for NC Innovations Waiver Application Closes on 7/30/2023

• Public Comment on Innovation Waiver Draft Application Ends July 30 | NC Medicaid (ncdhhs.gov) 

NC DHHS Rolls out I/DD Residential Provider Needs Assessment Survey (participation voluntary)

• NC State Developmental Centers: I/DD Residential Provider Needs Assessment Survey (office.com)

National News of Interest

• Office of Public Affairs | Court Finds State of Florida Violates the Americans with Disabilities Act By Institutionalizing Children with Disabilities | United States Department of Justice
• HHS Language Access Progress Report – OCR Will Hold Providers to the “Highest Bar” | McGuireWoods LLP – JDSupra

I/DD Legislative Priorities for North Carolina Organizations

Many organizations in North Carolina decide to focus on advocating by educating and informing on issues. Click here for a list of those organizations and the resources they offer.