June 2023: Climbing the Same Mountain Together

Sarah Pfau, JD, MPH,
Senior Consultant
CCR Consulting

Policy updates as of June 30, 2023

1915(i) State Plan Option Update

Note from LAND: As of June 30, we have information that the Centers for Medicare and Medicaid Services (CMS) has approved its proposed 1915(i) State Plan Option for NC. As of the publication of our June newsletter, we have not received a formal announcement from NC DHHS. Disability Rights NC has developed an easy-to-understand info sheet about 1915(i) found at  https://disabilityrightsnc.org/news/1915i-services/.

To date, the Division of Health Benefits (State Medicaid agency) has been projecting a July 1, 2023 starting date. LME/MCOs will have 90 days to implement 1915(i) after the State has a CMS approval date for go-live.

• The May 2023 NC DHHS Provider Playbook Fact Sheet contains a lot of helpful information about 1915(i).
• You can learn more about 1915(i) State Plan Options here on the CMS website.
• The latest round of draft Medicaid clinical coverage policies for the 1915(i) State Plan Option are posted here for public notice and comment:
• Respite (comment deadline July 3)
• Individual Placement and Support (comment deadline July 8)

Submit comments for policies by emailing: medicaid.public.comment@dhhs.nc.gov.

New NC Department of Health & Human Services (DHHS) Comprehensive Independent Assessment Entity for the Community Alternatives Program (CAP)/C, CAP/DA, PCS, and PASRR Level II

On June 15, 2023, NC DHHS announced that they awarded Keystone Peer Review Organization, Inc. (Kepro) the contract as the Comprehensive Independent Assessment Entity (CIAE) for the NC Medicaid program.  Beneficiaries and providers will have a single point of entry for obtaining long-term services and supports (LTSS) programs in NC Medicaid Direct [for fee-for-service services that are carved out of Medicaid managed care]. The point of entry will be branded as NC Medicaid Linking Individuals & Families for Long Term Services and Supports (LIFTSS).

NC LIFTSS will:  

• Process referrals;  
• Perform option counseling;
• Conduct assessments and quality assurance reviews;
• Provide service plan management and customer service; and
• Conduct provider training for the following LTSS programs: State Plan Personal Care Services (PCS), Community Alternatives Program for Children (CAP/C) and Community Alternatives Program for Disabled Adults (CAP/DA). 

NC LIFTSS will also provide management and oversight for the Pre-Admission Screening and Resident/Review process (PASRR) Level II and serve as North Carolina’s Transition of Care Coordinator (TCC) for nursing home residents who request information about options for less restrictive care settings.  

Over the next few months, NC Medicaid will conduct a phased implementation of NC LIFTSS and informational webinars for providers and beneficiaries. For more information, see the press release: NCDHHS Awards Contract for Comprehensive Independent Assessment Entity

The Centers for Medicare and Medicaid Services Home and Community Based Services (CMS HCBS) Access Rule Notice and Comment Period Ending Soon

The Centers for Medicare and Medicaid Services (CMS) Home and Community Based Access Proposed Rule 60-day public notice and comment period will end on July 3, 2023.

Comments must be submitted online by midnight on July 3, 2023. 

• Here’s the CMS Press Release, Proposed Rule summary, and link to the proposed rule:  Ensuring Access to Medicaid Services (CMS 2442-P) Notice of Proposed Rulemaking
• Here’s a helpful Administration for Community Living Proposed Rule breakdown:  Input Needed: CMS Proposes Rule to Improve Access to and Quality of Medicaid Services
• Please also see the presentation slides for Understanding the Proposed HCBS Access Rule for a helpful breakdown of the Proposed Rule’s sections that include proposed 1915(c) Waiver waiting list reporting requirements, Direct Care Professional wage pass-through requirements, Person-Centered Planning requirements, and more. Slides 18 – 22 include some helpful visuals for explaining CMS functions and the various types of Medicaid Waivers and State Plan options and federal laws that shape programs and policies. 

Once CMS finalizes the Proposed Rule, we will see amendments to the federal regulations for the Medicaid program. Those amendments will affect State Medicaid programs, North Carolina’s Standard Plan and Local Management Entity/Managed Care Organization (LME/MCO) managed care plans, Medicaid-enrolled provider agencies, and individuals who are enrolled in Medicaid and using HCBS services. 

State Budget Update

Although the new State Fiscal Year will begin on July 1, the North Carolina General Assembly Member State budget negotiations have stalled.  Members will not be convening conference committees again until after the July 4th holiday.  We will continue to monitor legislative activity, and we hope to have a more informative update for you about Direct Support Professional wage increases, new Innovations Waiver slots, and more in the July newsletter!  

Here is a Personal Care Services rate update:

• Rates are currently at $23.84 and that includes both an Electronic Visit Verification (EVV) enhanced rate component and a COVID-19 enhanced rate component.
• On July 1, the COVID-19 enhanced rate component will end, yielding a rate of $19.46 unless NC DHHS receives confirmation from the NCGA budget leadership that a rate increase (from $19.46 to $23) will be included in the budget with a corresponding (and necessary) appropriation.
• Since we don’t have a State budget by July 1, the PCS rate will remain lower ($19.46) until a State budget is passed. Assuming that the final budget will include the increase to offset the end of the COVID-19 enhanced rates, the new $23 rate, whenever it is enacted, will be retroactive to July 1. 

Here is a helpful, two-column comparison from NC Health News of the House and Senate Health Services related provisions in the two versions of a State budget (in addition to the Governor’s budget) that we have seen to date in 2023:  A guide to the 2023 legislative health budget  

NC Brain Injury Association and Department of Mental Health/Developmental Disability/Substance Abuse Services (DMH/DD/SAS), TBI Waiver & LME/MCO Expenditure Updates 

• Bi-Annual Needs and Gaps Survey Results 
• Division of Health Benefits (NC Medicaid) Updates

June Updates from DMH/DD/SAS: 

1. Competitive Integrated Employment (CIE) Request for Application (RFA) Update: June 16th was the extended application deadline.  However, the Department will still make a determination by 7/1.
2. Area Health Education Centers (AHEC) Direct Support Professional (DSP) Certification Project: NC Department of Mental Health (DMH) is working with AHEC to evaluate DSP certifications in the field.  Will include all DHHS services (Innovations, CAP/C, CAP/DA for I/DD).  Some agencies have their own certifications; some have transferable certifications.  DMH will recommend next steps for NC.  DMH is looking for participants from the provider world and LME/MCOs and is also coordinating with the NC Developmental Disabilities Council. 

June Updates from Department of Health Benefits (DHB), a Division of the NC Department of Health and Human Services: 

DHB is working on 10/1/2023 Tailored Plan Amendments for the Traumatic Brain Injury (TBI) Waiver and Innovations Waiver which include: 

Summary of changes included in the 10/1 TBI Waiver draft amendment:

• Added language that from 10/1 on Alliance will be a TP and the TBI Waiver will fall under the 1115 authority.
• Flexibilities NC Medicaid anticipates requesting be made a permanent part of the TBI Waiver Service array:
  • Home Delivered Meals (up to 1 meal per day)
  • Waive requirement for beneficiary to attend the Day Supports provider once per week.
  • Direct care services may be provided in a hotel, shelter, church, or alternative facility-based setting or the home of a direct care worker because of COVID-19-related issues.
  • Real-time, two-way interactive audio and video telehealth for the following services:
    • Life Skills Training
    • Cognitive Rehabilitation
    • Day Supports
    • Supported Employment
    • Supported Living
    • Community Networking

Summary of changes included in the 10/1 Innovations Waiver draft amendment:

• Flexibilities NC Medicaid are requesting to be made permanent as part of the Innovations Waiver Service array:
• Home Delivered Meals (up to 1 meal per day)
• Waive requirement for beneficiary to attend the Day Supports provider once per week.
• Direct care services may be provided in a hotel, shelter, church, or alternative facility-based setting or the home of a direct care worker because of COVID-19-related issues.
• Real-time, two-way interactive audio and video telehealth for the following services:
  • Community Living
  • Day Supports
  • Supported Employment
  • Supported Living
  • Community Networking
• Relatives of Innovation Waiver Beneficiaries will be allowed to provide up to 40 hours total of Supported Living
• Parents of minor children receiving Community Living and Support may provide these services to their child who has been indicated as having extraordinary support needs as evidenced by a Supports Intensity Scale (SIS) category of E (Very High General Support), F (Extraordinary Medical Support), and G (Extraordinary Behavioral Support Need).
• Increase in annual Innovation waiver cap from $135,000 to $157,000.
  •  Resource Facilitation will be removed from the TBI Waiver.
    • Resource Facilitation role is duplicative of Tailored Care Management
  • Relatives of TBI Waiver Beneficiaries will be allowed to provide up to 40 hours total of
    • Life Skills Training and/or
    • Personal Care 

I/DD Legislative Priorities for North Carolina Organizations

Many organizations decide to focus on advocating by educating and informing on issues. Some of their resources can be referenced below.

NCCDD (North Carolina Council on Developmental Disabilities)

• 2023 Public Policy Priorities
• Policy education meetings every second Thursday of the month from 10:30am-12:00pm via Zoom

The Arc of NC

• Legislative Agenda 2022-23
• Weekly Wrap-Ups with Executive Director, John Nash

Disability Rights NC

• A Summary of DRNC’s 2023 Advocacy Targets

Autism Society of NC

• 2023-2024 Policy Targets

The Coalition

• 2023 Coalition Legislative Budget Priorities