MEDICAID WAIVERS 101
LME/MCO Basics
In North Carolina, the state Division of Medical Assistance (DMA) has contracted with Local Management Entities/Managed Care Organizations (LME/MCOs) to administer Medicaid and State-Funded behavioral health services. Behavioral health services include mental health, intellectual and other developmental disabilities and substance abuse services. There are currently eight of these entities that operate in different geographic areas of the state. For example, Alliance Behavioral Healthcare is the LME/MCO for Wake, Durham, Johnston and Cumberland counties. If your client needs any of these services, they should contact the LME/MCO whose catchment area they live in.
The Innovations Waiver (discussed below) is administered by the LME/MCOs. The CAP C and CAP DA Waivers are administered through Lead Agencies overseen by DMA.
Background
The term 1915 (b)(c) Medicaid Waiver refers to two sections of the Social Security Act that allow states to apply for waivers from federal Medicaid policy. The (b) Waiver permits North Carolina to implement a Managed Care delivery system and allows the LME/MCOs to limit the provider network. The (c) Waiver (also called the 1915 HCBS Waiver) provides home and community-based services to Medicaid beneficiaries who would otherwise be institutionalized. The (c) Waiver allows for long term care services to be provided to recipients in the community rather than institutional settings.
The (b)(c) Waiver operates as a “capitated” system; the LME/MCOs are provided a pot of money each year from which to provide services to all Medicaid eligible individuals in their catchment area. The LME/MCOs are then “at risk”– if they spend too much, they will lose money – if they spend less than allotted, they are supposed to use the savings to provide additional services.
The idea of the Waivers was to control escalating Medicaid costs.
States have the discretion to choose the number of recipients that will be served in an HCBS Waiver program.
Why are they called Waivers?
The Medicaid Home and Community-Based Services (HCBS) waiver program that is authorized in §1915(c) of the Social Security Act permits North Carolina to furnish an array of home and community-based services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the needs of the waiver’s target population.
These programs are called “Waivers” because North Carolina is permitted to “waive” certain Medicaid requirements in the administration of the program. For example, Medicaid requires that the income of a spouse or parent be considered in determining Medicaid eligibility for a person living with that spouse/parent. Under the Innovations Waiver, this requirement is “waived” so that only the recipient’s income is considered. The Act also requires states to provide comparable services in amount, duration, and scope to all Medicaid recipients. This requirement is waived to allow Waiver services to be offered only to individuals who receive a Waiver slot.
3 North Carolina HCBS Waivers
CAP/C
CAP/C (Community Alternatives Program for Children) is a Medicaid program that provides home care for medically fragile children (through age 20) who would otherwise require long-term hospital care or nursing facility care (only the child’s income is used in determining whether the child is Medicaid eligible). By providing in-home nursing care, case management, and other supports, CAP/C helps children remain at home with their families. This program is overseen by DMA but uses local lead agencies for implementation, often County DSS agencies.
See Clinical Coverage Policy 3K-1 for CAP/C eligibility criteria.
CAP/DA
The CAP/DA (Community Alternatives Program for Disabled Adults) program waives certain NC Medicaid requirements to furnish an array of home and community based services to adults (18 years of age and older) who are elderly, blind or otherwise disabled. The services are designed to provide an alternative to institutionalization for recipients who prefer to remain in their homes, and would be at risk of institutionalization without these services.
CAP/DA services are intended for situations where no household member, relative, caregiver, landlord, community/volunteer agency, or third party payer is able or willing to meet the needs of the recipient.
There is a consumer directed option also available under CAP/DA called CAP/Choice.
CAP/Choice, allows beneficiaries and their caregivers to direct their own services and supports which are provided in their own primary private residence and community. It offers beneficiaries the choice, flexibility and control over the types of services they receive, when and where the services are provided, and by whom the services are delivered.
See Clinical Coverage Policy 3K-2 for Eligibility Criteria for CAP/DA.
Innovations Waiver (formerly CAP MR/DD)
The North Carolina Innovations Waiver is a Home and Community-Based Services Medicaid program that provides services and supports for individuals with intellectual and/or developmental disabilities who are at risk of institutional care in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IDD). The Innovations Waiver is the replacement for the CAP-MR/DD program. The goal is to provide an array of community-based services and supports to promote choice, control, and community integration as an alternative to institutionalization. These are services that are not otherwise available under the State Medicaid Plan.
Unfortunately, there are only a limited number of Waiver “slots,” so that although an individual may be eligible for the Waiver, there may not be a slot available for them to be able to receive services. However, there is a wait list for the program known as the Registry of Unmet Needs that is kept by the LME/MCO. The Registry of Unmet Needs operates on a first come-first served basis, so the sooner an individual gets on the list, the sooner they may be able to receive services. In certain limited circumstances, there are Emergency Waiver slots available.
Because of the high demand for these services, the wait list is extremely long and it could take many years before a slot becomes available to an individual on the waitlist. The Innovations Waiver currently has the capacity to serve 12,488 people in NC; however, there are still approximately 9,000 people on the Waitlist.
An individual can request to be placed on the waitlist by contacting their LME/MCO. It is best to request that an individual be placed on the Innovations Waiver waitlist in writing and have the LME/MCO confirm in writing that they have done so and the date it was done.
There is no entitlement to services under the Waiver program before a slot becomes available. However, once a person is placed on the Registry/Waitlist, the LME/MCO should refer that individual to other resources that may be available while they are waiting for a Waiver slot to open up.
Note that eligibility for Innovations Waiver services is not dependent on income because this Medicaid requirement is “waived”.
The Future of the Innovations Waiver
North Carolina is in the process of requesting that CMS approve an amendment to the Innovations Waiver. If approved, as expected, the new Waiver will take effect on January 1, 2016. At this point, it appears that all participants in the program will be “cross-walked” to the new Waiver beginning in January 2016.