Understanding Services: Where and
How to Get Help
Jennifer Mahan - Director of Advocacy & Public Policy
What are we going to talk about?
 What are services and how are they funded?
 How is the system managed?
 Where do I get help for my child/self/family
member?
 Q&A
What are Services?
 What are they?
• Services are extra help or assistance for your family
member with autism that can be applied for through the
“mental health system.”
• Families who have family members with disabilities or
people who have disabilities can apply for these
services.
• Services can include help linking up with other
resources, one on one instruction for people in their
homes and communities, training for families and
respite care.
• Services are based on a plan developed after
assessments and an eligibility determination process.
What Are Services? Who Qualifies
 Who Qualifies ?
• Qualification for some NC services is based on need –
not income!
• Some services are limited to low income people
• A diagnosis of a disability does not guarantee that
someone will qualify and receive services.
• Criteria for qualifying for NC need based services
– Must have substantial, functional limitations in 3 or more
areas of life activity
– Life Activities: Self-care, understanding and use of language,
learning, mobility, self direction, capacity for independent
living
What are Services? Funding
 Who funds services?
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Private Pay/Private Insurance/Other sources
Schools (for services during school day for ed.)
State Funds/IPRS and “B3”
Medicaid
 Services vary across the state depending on who
funds them and how much funding exists.
 Services also vary depending on the availability of
qualified providers.
What are Services? Funding
 Private Pay: Self (you) pay
 Insurance: Coverage varies, may have coverage for
physical health, mental health care, OT, speech
therapy but all autism services not covered
 Other: Early intervention may be covered though
public health, military via Tricare and ECHO
 Schools: Under Federal law (IDEA), may cover
those things that assist with the child’s learning and
education
What are Services? Medicaid
 Medicaid (federal funds with state match)
• “Traditional” Medicaid
– Doctor visits/Emergency Room/Medication
– ICF-MR (Intermediate Care Facilities)
– Other LTC: Personal Care, Adult Care Home, Nursing Home
• Medicaid “Enhanced” Services
– Mental Health and Addiction services and supports
– “B3”- basic supportive MH, IDD, SA services
• EPSDT – Early Periodic Screening Diagnosis and Treatment
– Catch-all funding for children – but not habilitation services
• Medicaid Home and Community Based Waivers under
Managed Care
– NC “Innovations” Waiver under managed care
– Other CAP programs for children, disabled, elderly
How is the services system managed?
 Federal and State government provides overall
funding and policy direction ($, laws, regulations)
 State (MHDDSAS and Medicaid) directs funds,
policies, oversight, accountability
 LME MCO: Local Management Entity manages
provider network, authorizes services, provides
care coordination
 Private providers provide services and supports
 Services are paid for on a fee-for-service basis, but
funds are managed using “capitation” : provider
bills, LME pays out of a set amount of funding
What do we mean by “Medicaid
Managed Care?”
 HMO type model: pre-paid, shared risk healthcare
• Local, state and federal funds pooled into a per member
per month (PMPM) rate paid to LME/MCO
(“capitation”)
• LME/MCO manages funds & is responsible for cost
overruns, sets guidelines w/ state regarding use of $
• Payment and rate structure may vary
 Limits choice of provider: LME determines
 Replaces case management with Care Coordination
and Community Guide
 LME/MCO responsible for utilization review, plan
development, resource allocation, fiscal
management, care coordination.
Innovations Waiver Basics
 I/DD home and community services waiver for
people is called “Innovations Waiver” and is
similar to Community Alternatives Program (CAP)
 Provides aggressive, goal driven, active treatment
for individuals with I/DD who are not able to
function safely and independently and who are at
risk for placement in intermediate care facilities
(ICF-MR)
 Served in community/home settings
 Looks only at individual income
 Uses an assessment and resource allocation to
determine an individual budget for services
Innovations and the “Wait List”
 Innovations is not an entitlement: limited slots and
funds
 The Wait List includes those waiting for a slot in
Innovations/CAP IDD
 The Registry of Unmet Needs includes those
waiting for other services
 Waiver slots are generally managed on a first come
first serve basis
Innovations Continued
 Some Innovations slots may be aside for specific
populations (but not all LME MCOs can or do set
aside slots):
• Individuals at significant risk of harm
• Individuals moving from another waiver
• Individuals receiving waiver services in another state
who are transferred to NC for military service
• children 0-17 moving from an institution
Care Coordination
 Care Coordination is NOT case management
 Care coordinators are employed by the LME MCO
 Care coordinators can assist with individual
support plans, but they set very broad goals
(Providers will set specifics and shorter term goals)
 Not everyone will have care coordination, but
those on Innovations should have it
 Meetings may occur more often over the phone,
rather than in person
List of Current Innovations Services
Innovations Services
• Assistive Technology, Equipment and Supplies (GPS and Personal
Emergency Response included)
• Community Guide, Community Networking, Community Transition
• Crisis Services (includes some Crisis Respite, Behavioral Consultation,
etc.)
• Day Supports
• Financial Support Service, for those with employer of record
• Home and Vehicle Modifications ($ limit over 3 years)
• In-Home Intensive Support
• In-Home Skill Building
• Personal Care
• Residential Supports
• Supported Employment
• Respite, Nursing Respite for exceptional medical needs
• Natural Supports Education
• Individual Goods and Services (setup for transition from institution)
• Specialized Consultation Services
• (Transportation is eliminated but included in provider rate for services)
What are “B3” Funding and State
(Formerly IPRS) Funds?
 Medicaid “B3” (MCO funds) and State Funds
(IPRS) that fund additional services
 They vary from MCO to MCO
 [MCO staff has info on what services are available
in your area]
Alliance B3 Services
 Alliance currently has Community Guide and
Respite B3 services
 Alliance may have some Personal Assistance,
Developmental Therapy, and Employment IPRS
funded services – the availability of these servceis
varies by which county you live in
Additional (b)(3) Medicaid Services
(for Cardinal Healthcare Region Only)
November 2012
(b)(3) Service
Population Served
Disability
Community Guide
Child (3+), Adult
I/DD
Community Transition
Adult (21+)
I/DD
De-Institutionalization
Service Array
Child (3+), Adult
(discharged from ICFMR)
I/DD
Respite
Child (3+), Adult
Child Age 3-20
I/DD
MH/SA
Supported Employment
Adolescent (16+), Adult
I/DD
Individual Support
Adult (18+)
MH
Peer Support
Adult (18+)
MH/SA
Psychiatric Consultation
Child (3+), Adult
MH
Not in Alliance or Cardinal?
 Check the map earlier in the presentation to find
your LME MCO or view the map here:
http://www.ncdhhs.gov/mhddsas/lme-mcomap1013.pdf
 Check the list of local contact to find your county
and LME MCO
http://www.ncdhhs.gov/mhddsas/lmeonblue.htm
ASNC Services - Triangle
 ASNC offers services in the Triangle region:
http://www.autismsociety-nc.org/index.php/gethelp/direct-care/raleigh-autism-society-of-northcarolina-office
 Talk about how to access services and supports
• Alliance Website for Individuals and Families:
http://www.alliancebhc.org/consumers-families
ASNC Services – Cardinal and
Statewide
ASNC offers services in other regions of the state,
including some of those served by Cardinal:
http://autismsociety-nc.org/index.php/gethelp/direct-care/autism-society-of-nc-servicesoffices
 Talk about how to access services and supports
• Cardinal Innovations Healthcare Solutions :
http://www.cardinalinnovations.org/consumerfamily/
Being Your Own Case Manager
 Stay in contact with LME & care coordinator
 Come prepared with the goals you want to work on
 Work with provider agency on goals
 Ask what resources are available: ask for what you
need
 Get and retain documentation of needs
 Document all conversations with the LME and
providers (date, time, what was concern, what
solutions were offered, what was outcome)
Complaints
 Each MCO has a grievance process that notes
complaints that are not related to reductions in
services
 Complaints can be about anything:
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Quality of care from provider
Problems with care coordination
Problems getting the right information
Impact of cuts on service provider
Problems getting “enrolled” in services (access)
Other situations that come up
Appealing Reduction in Innovations
Waiver Medicaid Services
 MCO must provide written notification of decision
to reduce, deny, terminate services
 Under MCO, you have a set number of days to
begin appeals process
• 1st step is internal review (peer review)
• Mediation may take place
• Next level is informal OAH hearing
 See Information on MCO website
Weblinks:
 Alliance LME MCO
• IPRS services http://www.alliancebhc.org/iprsadult-and-child-idd-benefit-plan
• IDD resources
http://www.alliancebhc.org/consumersfamilies/idd-resources
 Cardinal Innovations Healthcare
• Accessing Services
http://www.cardinalinnovations.org/consumerfa
mily/services.asp
• Innovations Waiver
http://www.cardinalinnovations.org/innovations/
Weblinks:
 NC Department of Health and Human
Services
• Division of MH/DD/SAS:
http://www.ncdhhs.gov/mhddsas/
• 1915 b/c Waiver:
http://www.ncdhhs.gov/mhddsas/providers/
1915bcWaiver/index.htm
• Medicaid:
http://www.ncdhhs.gov/dma/medicaid/inde
x.htm
Contact Info
 Jennifer Mahan, Dir. of Advocacy & Public Policy
ASNC Raleigh Office
jmahan@autismsociety-nc.org
Tel: 919-865-5068
 Kerri Erb, Senior Director of Programs and Quality
ASNC Raleigh Office
kerb@autismsociety-nc.org
Tel: 919-865-5053
www.autismsociety-nc.org