1915(b)(c) Waivers

Additional background and commentary can be found at ncmentalhope.org/commentary. This page is intended to list concerns expressed over aspects of the plan for statewide managed care of mental health, developmental disabilities and substance abuse services through 1915(b)(c) waivers. This page is not intended to list the pros and cons of such waivers, but to list concerns to give some balance to DHHS’s overly positive reports. North Carolina Mental Hope is not as concerned about what the waivers will mean but in the lack of consumer inclusion and transparency in how they were developed and are being implemented.

With the Department of Justice investigating North Carolina’s mental health system, is it wise to lock the state into a system that DHHS Secretary Lanier Cansler has said “requires major changes in both service delivery and financing?” An October settlement between the DOJ and Georgia over that state’s mental health care requires the state to overhaul its system and increase funding $79 million over the next two. How much more expensive might North Carolina’s cost be with the added expense of dismantling the major changes connected with the waiver expansion?

Chapter 122C of the North Carolina General Statutes requires the Secretary of Health and Human Services to provide staff and data to the State Consumer and Family Advisory Committee necessary for it to fulfill its advisory role in planning and monitoring MH/DD/SAS services.

The Division of Mental Health, Developmental Disabilities and Substance Abuse Services is acutely unprepared to oversee 1915(b)(c) waivers statewide, according to an August 2010 Mercer Consulting report. It is ludicrous to think that with an austere budget and in such a short time, problems of the magnitude found by Mercer could be corrected. Those problems included: lack of staff training; an archaic IT infrastructure with an IT staff worried that significant component failure could occur at any time; a critical lack of Quality Management; and a need to develop a basic shared vision, guidelines, policies, and procedures.

Questions of common sense have to be asked. If statewide implementation of managed care waivers is so desirable, why was public announcement of the expansions made three weeks after enabling legislation was introduced? Why have Requests for Applications been sent out before the entity LMEs are applying to become is even legal? Why is the need for multiple years of research and planning Secretary Cansler said was needed in a July 2009 report to legislators no longer needed? Why, especially considering the wide distribution of Mercer’s 2008 report on LMEs, were findings of its 2010 report that found DHHS unprepared for waiver oversight not shared with legislators or advisory bodies? And why should legislators believe that the Department has fixed the problems it didn’t share in the first place?

The waiver is being expanded to the state’s 100 counties based on a pilot project of one LME serving five counties, the only LME presently operating under a 1915(b)(c) waiver. It has been routinely implied that waivers are in place at other LMEs and that 1915(b)(c) waivers have been an integral part of the state service plan since 2005.

This issue may well be resolved by introduction of the latest bill, House Bill 916, on May 5. Targeted Case Management Services to 16,500 individuals with intellectual or developmental disabilities who are not eligible for any entitled services would be cut. Under 1915(b)(c) waivers, Case Management would be eliminated, replaced by Care Coordination. Case Management allows for a spectrum of help that can include finding and coordinating services, monitoring services, assisting with issues such as guardianship and Individualized Education Plans, and helping arrange transportation and medical needs. Care Coordinators will coordinate only entitled services for these individuals, who, since they have no such services, will also no longer have Case Management as a lifeline.

The Arc of NC’s view may have well changed with introduction of the latest bill, House Bill 916, on May 5. The Arc of NC says the waiver expansion is “a much more radical change in system design than Mental Health eform” and is not in the best interest of people with developmental disabilities: “The reckless pursuit of a Behavioral Health Managed Care system threatens the core supports of people with Developmental Disabilities.” Disability Rights also expresses concern that the focus of managed care is on acute health service and that the long-range supports needed for the wellbeing of many will suffer.

Other concerns raised include: geographic inequities, the lack of consumer protection, and, as mentioned in the Mercer Report, the lack of quality management in program implementation and service delivery. At present, LMEs essentially monitor their own performance. Disability Rights notes concerns over the failure of managed care models to promote community integration, self direction and independence.

Incorporating 1915(b)(c) waivers imposes yet a new layer of regulations, applications and other stipulations with which providers must comply. The onerous amount of paperwork that may be manageable for larger employees with larger staffs, it may simply be too much for some small providers to deal with.