The 1915 b/c Medicaid
Questions & Answers
Table of Contents:
Care Coordination Questions……………………………… 3 - 5
CAP/IDD/Innovations Questions …………………………. 6 - 9
LME/MCO/ Med Waiver Transition Questions………….. 9 - 13
Provider Network Questions………………………………. 13 - 14
Treatment Plans/Assessments Questions…………………. 15
Community Guides Questions…………………………….. 15 - 16
Funding, Fraud, Appeals, Hours Questions…………........ 16 - 17
Waiting List Questions…………………………………….. 18
Family Members/Non-Family Members
as staff, etc. Questions……………………………………… 18
Members and Their Needs Questions…………………….. 18 - 20
“Other” Questions…………………………………………. 20
Questions & Answers/Categorized
Questions Pertaining to Care Coordination:
1) A question was asked in reference to when/how a MH/SA consumer is contacted by Care
LME/MCO’s will be notified when an individual is admitted to the hospital for MH or SA. The
consumer will receive help with the discharge from a licensed clinician. If a consumer has been
contacted by mobile crisis three times within a set period of time, it will come to the attention of
a Care Coordinator who will help connect the consumer with a CABHA to assist in meeting the
needs on an out-patient basis. The consumer will be given choices of providers. The provider
chosen by the consumer will make contact and come up with a treatment plan based on the
2) How does a Care Coordinator differ from a Case Manager?
Care Coordination is not a service. It is an outcome-driven function with some of the same
components as Case Management.
3) Will Care Coordinators be assigned by SHC?
Yes, and if problems arise with the Care Coordinator you have been assigned to, let us know and
another can be assigned to you.
4) If consumers have problems after July 1, will they go to Sandhills Center rather than
their case manager?
Yes, it would be best to talk to the Care Coordinator; however you may call the 800 #.
5) Is a Care Coordinator the same as a Case Manager?
Care Coordination is a “function.” Case Management is a “service.”
6) How does one get access to a care coordinator?
We will identify people who need Care Coordination through informational reports in order to
connect them with a provider. The reports may indicate diagnoses and other information. Care
Coordination can connect the consumer with a provider and monitor cases, as needed.
7) When will consumers be contacted by phone by a Care Coordinator?
Consumers/families should be contacted by the end of May to the first of June, 2012.
8) How often will Care Coordination meet with the provider?
There will be at least monthly monitoring, including face-to-face meetings. There will be more,
9) Who will be responsible for evaluations and interviews…Care Coordination or Licensed
The state has not yet made that clear. We are still waiting on an answer.
Sandhills Center will be controlling the pot of money.
10) Will Care Coordinators come to the home or make contact by phone?
Beginning in March, 2012, a Care Coordinator will make a visit to get acquainted with the
consumer/family. The Care Coordinator will have a face to face contact at least monthly, and
more if needs change.
11) If only Medicaid funded services are currently being received, including case
management, will this continue?
The consumer will be assigned a Care Coordinator.
12) How is Care Coordination monitoring different for consumers living in their home and
those living in a facility?
Individuals new to the NC Innovations waiver will be monitored by Care Coordinator monthly
face to face visits for the first six months. After that, quarterly face to face monitoring will
occur. However, if an individual’s needs warrant monthly monitoring from a Care Coordinator,
then this will occur and will be reflected in the ISP. Care Coordinators are required by the
waiver to make monthly face to face contacts for all participants residing in a residential setting,
those individuals who have relatives/family members providing direct waiver services, and
individuals who are self directing their services.
13) Can any consumer receive Care Coordination?
Care Coordination is available to consumers who meet the criteria and are eligible.
14) Who makes referrals for Care Coordination for consumers?
Anyone can make a referral.
15) What will take place during the initial contact by the Care
The Care Coordinator will make contact with the consumer or family member to set up a
meeting to discuss transitioning into Innovations. All services will cross-walk over to
16) Do guardians get to choose their care coordinator?
No, one will be assigned, but if there is a problem with your Care Coordinator, let us know and
we’ll work with you.
17) Is Care Coordination only for those eligible for Innovations?
Care Coordination is available for eligible consumers through regular Medicaid and for MH/SA
and IDD services.
18) Will consumers/families meet with Care Coordinators?
Care Coordinators will meet with consumers/families concerning the transition and their services
that will cross-walk over to Innovations.
19) Is Care Coordination available for all consumers?
All consumers with diagnoses of IDD are assigned a Care Coordinator by SHC. Consumers with
diagnoses of MH/SA who have had an episode of acute care need will be assigned a Care
Coordinator to help the consumer move through and out of the crisis state. All children in
transition, such as to a group home, are assigned Care Coordinators.
20) How is Care Coordination prevented from being a conflict of interest?
Care Coordination bases services on the needs of the individual, through an assessment. Care
Coordination submits a plan to Utilization Management who will make the final determination of
services to be received.
21) How will Care Coordinators be assigned?
SHC will assign the Care Coordinators, but if there are grievances, a plan is in place to change
Care Coordinators if the consumer/family so desires.
22) A question was asked in reference to when Care Coordinators will begin to talk with
consumers about the transition.
Care Coordinators will begin screening in March, April, May, and June to identify consumers’
services which will cross-walk to Innovations.
23) Will Care Coordination meet with consumers monthly?
With Innovations, a monthly face-to-face visit is required for the first six months. After the
initial six months, meetings may be quarterly. If needed, however, meetings may continue on a
24) What will the case load be for a Care Coordinator?
The case load will be a little over 35.
25) If the case load of a Care Coordinator is over 35, the numbers don’t seem to add up,
considering the current number of Care Coordinators.
There will be 18 Care Coordinators and more as needed.
26) Will Care Coordinators for substance abuse be licensed specific to substance abuse?
We have 1 ALCAS and licensed clinicians are trained regarding substance abuse.
27) Will a QP (Qualified Professional) or will care coordination be completing the PCP’s?
Qualified SHC Care Coordination Staff will complete the PCP’s – it will be an LME function.
28) Will consumers be assigned or allowed to choose our care coordinators?
Care Coordinators will be assigned for you. Procedures are in place to file a complaint.
29) When will our Care Coordinators be assigned?
We are currently identifying the individuals who will be receiving Care Coordinators and
assigning them. Once one is assigned a meeting will be set up with you to start the transition.
This is already taking place.
30) My child receives Early Intervention Services. When Care Coordination takes over,
will those start automatically?
Yes, they are a separate branch, so that will not be affected by the waiver.
Questions pertaining to CAP/IDD/Innovations:
1) A question was asked in reference to I/DD.
Tena Campbell will answer specific questions on I/DD.
2) If a consumer has been receiving CAP services for four years, what will be the process
for the transition?
The DMA has a specific number of slots available. Services will be based on cases which have
been carefully prioritized; just as CAP I/DD slots are currently handled.
3) Are there two separate waiting lists?
There is one waiting list for Innovations.
4) Does CAP/ID go away on 7/1/2012?
5) Previously, when CAP workers have been in the home, they have had the parents/family
members to sign off on the specific time the Cap worker was in the home, etc. This
documentation no longer is required. Without this documentation, it is a perfect set-up for
fraud. Why are we no longer asked to sign the form?
You may ask to sign off on the documentation if you wish to, even if it’s not required.
6) A question came up concerning how consumers would continue to receive needed
services, while Sandhills worked within the same budget, and could “hire & fire” staff as
they saw fit.
Services will “cross-walk” over from CAP/IDD to Innovations.
7) If we lose our case manager, what process is in place to receive specific handicap
equipment, such as a ramp?
Tena Campbell responded by saying there will be a transition plan for handling such requests
8) If consumers have been receiving home support services provided by family members,
seven days a week, will this continue?
Consumers will transition into the plan with the same services, and at the next annual plan, an
assessment will be conducted to determine the needs of services.
9) Will there still be respite care for those care-givers living in the home?
10) Will there be a change in services with the new Innovations?
No, services will cross-walk to Innovations, effective 7/1/12.
11) Will training be done in the home?
This depends on the provider; training will be handled in conjunction with the provider and SHC.
12) Will all services across the board continue with Innovations?
Services will cross-walk over to Innovations. “Innovations” is a different model, but transition
of services should be smooth.
13) My daughter receives services. Will I be able to discuss with a case manager each
change in service?
Tena Campbell will discuss CAP transition. Will be a process of pulling together case managers
into the system; case managers will work out with consumers how transition will work.
14) Will the current budget be in place when transitioning from CAP/IDD to Innovations?
15) Will consumers be able to continue with the same CAP workers?
Yes, if that particular provider is a part of the network.
16) How will a parent be notified about information on IDD?
Tena Campbell handles IDD and is very informed about this aspect of the change. She will
answer your question.
17) What is NC Snapp?
This is part of the CAP program, and Tena Campbell will discuss this topic in depth.
18) What does NC Snapp provide?
NC Snapp is the beginning of the evaluation process. It identifies the support the consumer
needs (behavioral, medical, etc.)
19) What if I have both Medicaid and state-funded services?
State-funded services will continue. B-3 is a Medicaid service which is part of the waiver, with
20) Does CAP/ID go away on 7/1/2012?
21) What services will be available to consumers who do not get CAP services?
The services consumers are currently receiving will continue and transition over to Innovations
July 1, 2012.
22) Are there qualifications for staff who work in group homes?
Yes, some require staff to be independent licensed clinicians. There are various qualifications
that must be met.
23)When will Care Coordinators meet with IDD consumers?
Tena Campbell will be having a meeting on this Wednesday, Feb. 29, 2012.
24) Will assessments be conducted by MCO’s?
Yes, the MCO’s Care Coordination Department will conduct assessments.
25) What is the number of hours available for respite?
With Innovations, the hours are based on individual needs.
26) A question was asked in reference to day activities available under Innovations.
Day activities might be things such as arts and crafts activities. An activity such as taking a child
shopping would probably come under the “in-home” portion of Innovations.
27) A question was asked in reference to April 1, 2012 changes in CAP I/DD.
SHC will be included in a phone conference to learn about these changes.
28) Will consumers on Innovations be assigned Care Coordinators by SHC?
29) With Innovations, if an individual receives CAP services and goes into a crisis, what
will the protocol be?
The protocol will not change from the current one. Mobile Crisis services are provided and a
Care Coordinator will follow the consumer to see that services are provided and individual is
30) What is the time line for the CAP waiting list?
Slot allocations from the state are received, prioritized, and is the basis for the waiting list.
31) The waiting list continues to be based on slots from the state?
Yes, but with CAP I/DD, if service is terminated it goes back to the state. With Innovations, if
service is terminated, it can be used by another individual.
32) With Innovations, are there more slots available for state-funded respite?
As of July 1, 2012, additional funds will be available, and there may be more slots available. To
answer this question, more information is required…we don’t know for certain at this time.
33) It has been hinted that our current CAP services will decrease as the new Innovations
comes into effect. Is this the case?
No, services which consumers are currently receiving will cross-walk over to Innovations. There
will be no immediate loss of services; as in the past, yearly assessments will be done to re-
evaluate the needs of the consumer and services will be provided based on those needs.
34) If services cross-walk to Innovations, will there be a cap on the amount allowed for
crisis services and behavioral consultations?
Yes, provider trainings will be held in reference to cap amounts for these services.
35) Why is Innovations on a “slot” basis, and how does that work?
Innovations works on slot allocations. If services are terminated for consumers, those funds will
be used for other consumers. Unlike the current CAP I/DD program, funds will not go back to
the state if services are terminated, but will be used by consumers who are in need of services
and are on a waiting list.
36) Will enhanced services transition over to Innovations?
As of April 1, 2012, enhanced services as they are known will no longer exist. However, a new
definition will cover such services and they will transition over into Innovations. For example,
“Home Supports” will become “In-Home Intensive Support and Personal Care.”
37) If we have IDD/ and High Risk members will they be limited to 180 hours or will it be
according to their needs?
Was provided with Tena Campbell’s number to obtain the answer.
38) My child is 2 1/2. What happens when she turns 3?
She will be eligible for services. Not necessarily CAP. Contact Sandhills Center now for referral.
39) With Compensatory Education, what role will the Case Manager play now? Will he go
to IEP meetings?
The Case Manager will now be the Care Coordinator. If you want your previous Case Manager
to go to meetings, he will have to be added as community guide.
40) Is CAP-C a different waiver?
Yes, that waiver is until age 21. So children can transition to Innovations at that point.
41) There’s been a 3-4 year wait for the CAP waiver program. Is that still true?
Not necessarily. If a slot opens during the year, we can reuse that slot for someone else at the end
of the year, instead of losing it like we did previously.
Questions pertaining to the LME/MCO/Med Wavier Transition:
1) In reference to the educational packets to be provided to consumers, how accessible will
they be? Will they be available in different languages? Will they be at appropriate reading
levels and simple formats?
Educational packets will be evaluated and approved to ensure the information is easily
accessible, easily read, clear and concise, and available in needed languages. Packets will be
available through the mail and our website. Questions may also be asked and answered online
through the website.
2) There will be lots of support care staff looking for jobs. What will happen to them?
We are taking applications at SHC for Care Coordination and Community Guide staff. They
may apply for positions at SHC.
3) Will Guilford County become a part of SHC?
SHC is currently talking with Guilford County and there is a possibility of a merger. Things
look positive, and a merger may take place around January 2013. SHC’s goal currently is to
successfully transition into the new waiver July 1, 2012, and to go forward from there.
4) If someone is having trouble finding the right medications needed, can we get help
finding places to go to, who have staff that can help with this?
Daymark handles medication and will continue doing this. If problems continue, Care
Coordination will step in to help.
5) In transitioning into the new waiver, will the current level of care be affected in the
Utilization Management will determine the level of care, but it is not as simple as resetting the
level to zero. Utilization Management will have information on what services consumers have
been receiving, and will go through a process of determining what level is needed. U.M. will
know what has been happening “clinically” with each consumer.
6) How will LME manage money and control services?
LME is encouraged to not make lots of changes in first year, allowing all to get used to the
system. The definition of “service” is a broad term.
7) Why is Sandhills Center going to MCO with all the problems/issues PBH is
Someone has to manage the Medicaid dollars…either the providers or the LME. Sandhills
Center is community-based and community-focused, with CFAC being greatly involved to
represent the consumers and families.
8) How are providers chosen to be in the network?
Any provider wanting to be in the network can apply. Providers must meet specifications and
required outcomes. If providers do not meet requirements, their contract will not be renewed.
9) How will authorizations be handled?
Sandhills Center will take over the responsibility of authorizations. Value Options will no longer
do authorizations as of July 1, 2012.
10) Will Sandhills Center have “due process?”
Yes, to the extent that Sandhills Center staff will be going to a three-day training on
standardization. It will be made very clear who has responsibility over DMA. Due process will
be “key” in all of this. We will be the agent for DMA…we are taking “vendorship” and we will
be their agent.
11) Will the MCO set rates?
Yes, the MCO will set rates, but there will be few changes for the first couple of years.
12) What happens when a consumer moves from one catchment area to another after July
Services will “cross-walk” from one catchment area to another. If the county is not with
Innovations, there will be a transition to CAP-I/DD.
13) If a consumer is mentally ill and living outside the Sandhills area, how will this be
handled if their Medicaid is from Randolph County?
SHC will still have responsibility for the consumer.
14) In transitioning to the new waiver, will funding for services, supplies, and equipment
come from SHC?
Services will not be an issue, as funds will come from SHC. The question is about supplies and
equipment. We will need more information before answering this question, and will look into
15) What local collaborations are LME’s currently doing? What is being done to “bridge
the gaps,” such as police trainings, etc.?
Agencies have had, and continue to have, the opportunity to collaborate with Sandhills Center.
Agencies have the opportunity to learn about the 1915 (b) (c) Medicaid Waiver at forums such as
this and through other means available. Agencies are encouraged to take advantage of these
16) Will the Call Center have Spanish-speaking staff available?
Gene McRae responded to this question saying the Call Center has access to a translation
service. The Call Center has a script, if needed, and if the caller requests a translator or if it’s
evident one is needed, the caller will be connected to a translator who can answer the question/s.
17) Will claims be sent directly to Sandhills Center, and if so will it be done electronically?
Yes, claims will be sent electronically to SHC. Providers will go through an orientation to learn
18) My daughter went to a psychiatrist who was treating her with medications requiring
blood test monitoring. The office was told that Medicaid would not pay for these blood
tests. It’s very difficult to get my daughter in to see a doctor. I can’t understand why
blood tests cannot be done in the same location with the psychiatrist. This would save
money and help parents and families who have a difficult time getting consumers into a
Victoria Whitt responded to this comment. Medicaid and Lab work for this type of hospital visit
is outside what we’re talking about. The question remains, will the capitated pot of money
include such lab work, etc.? Currently it is “fee for service,” but the big question is what will it
be in the future? SHC will funnel back with these great questions.
19) Will priorities be considered? Will consumers with the greatest needs get services
Tena Campbell answered this question with a “yes.” Those with the greatest needs will get
20) Will SHC have resources available to help families find caregivers?
SHC will have access to providers, but not individual caregivers.
21) Wouldn’t it help people if SHC could provide a list of a few caregivers that families
could call to get help in caring for their family member/consumer?
Tena Campbell responded by saying some providers do this, and hopefully expanding providers
will help make available more resources.
22) Will Sandhills Center be taking back to DMA any questions arising in these forums?
Victoria Whitt responded by saying Sandhills Center and CFAC are co-sponsors of these forums.
CFAC and Stakeholders’ committees are guiding and helping SHC on important aspects of
upcoming changes. Agencies such as police departments, DSS, etc. are involved and have
helped SHC learn there is a need to broaden the agencies with whom we collaborate. For
example, first responders are many and varied, and stakeholders’ committees can help us reach
many who have not been included. Yes, questions asked in the forums are being recorded;
questions coming up in the 2nd round of forums beginning in April will also be recorded, and
these questions will be used to gather and consolidate needed information to help make the
transition a smooth one. Ron Huber requested that anyone having additional questions record
them on the evaluation forms to be returned to SHC at the end of the forum.
23) Will Sandhills Center have access to hospitals throughout the state (as this individual
experienced the lack of knowing where to go when an episode occurs)? Another individual
added that in her experience with a handicapped adult daughter, hospitals do not know
how to handle people who have handicaps. She stated that hospitals need to know how to
handle people with special needs.
Sandhills Center has information on hospitals throughout the state. Hospitals are part of our
network and we will be providing much needed training for those within our network.
Value Options requested a family member to have a behavioral assessment done on her
daughter/consumer. Neither the provider nor family member knew where to go to have this
done. What should we do in a case like this? Please take advantage of the toll-free number and
call with any questions.
24) Will billing be handled by the MCO?
25) How will LME manage money and control services?
LME is encouraged to not make lots of changes in first year, allowing all to get used to the
system. The definition of “service” is a broad term.
26) Why was Guilford County not chosen to be an MCO?
Some LME’s did not qualify due to catchment population and the number of Medicaid-qualified
people within that area. Guilford County approached Sandhills Center, as they need an LME.
We are about two months away from making a decision on this. If we take Guilford County,
Sandhills Center will be the 2nd largest LME/MCO in the state. Lots of mergers are currently
27) What is the difference between an LME currently not in a conflict of interest situation,
and possible a conflict of interest when managing and handling funds as an MCO?
In prior years, we delivered services as a provider and paid providers for services. In 2001
Governor Easley made the decision that it was a conflict of interest to deliver services and pay
providers for the same services. In 2009 SHC became an LME to contract with providers for
services through a provider network, as we managed state dollars. We did not deliver services.
As an LME/MCO, we will assume the Medicaid function. We will not and cannot deliver
services as an MCO. We will be doing care coordination and utilization. There will be a
firewall to prevent any conflict of interest.
28) If a consumer goes to the E.R. and they are committed/released, does SHC follow up
with the individual?
Absolutely. We have access to IPRS and will have information on anyone on Medicaid. We
will make contact with the provider and our Hospital Transition Team helps handle that, using a
protocol to work more efficiently.
29) How will we be notified on the transition?
Tena will answer this question.
30) How do you know who uses services?
Any provider who makes a request for services will automatically be entered in the system.
31) What happens between now and July?
Consumers should continue to go to their service provider or call the 800 number to be
connected with a CABHA.
32) A question was asked in reference to merging with Guilford County.
SHC is talking with Guilford County about consolidation. LME’s have been informed that some
may need to find partners if their membership is not at least 500,000 as of 7/1/2012. SHC is
currently above the minimum of 500,000. SHC is not actively seeking partners, but is
considering merging with Guilford County since the time they came to us. Other LME’s have
also been coming together as a result of the minimum requirement.
33) With the mapping system, what specific service gaps have been found within our area?
I currently do not know the answer, but you may call the toll free number to get an answer to this
34) Where can we find which LMEs are merging?
Contact the Provider Help Desk.
35) If a child is in a facility and are not ready to transition to lower level of service, how will
this be addressed?
The providers are working with the families to determine if the child is ready to transition to a
lower level of care such as residential placement or if they will continue to need a higher level of
care such as an inpatient facility. Some services will be continued. Children receiving a certain
level of care have become disconnected from their community. When a child is ready to
transition the LME steps in.
Questions pertaining to Providers/Provider Network:
1) How is a provider selected?
The consumer/family will have options to choose from various providers in the network.
2) How will long-term vocational support work?
Long-term vocational support is a service for individuals who need help on an ongoing basis.
3) How can we be sure the Network is adequate to serve consumers?
There is already a gaps analysis in place and conducted on a regular basis. There are currently
lots of providers, and all providers in good standing with the DMA will be allowed into the
network. If SHC sees gaps, recruiting will be done to fill those gaps to ensure adequate
providers and services are available.
4) If a consumer is currently with a provider, can they remain with that provider?
Consumers will still have provider choice. As long as the provider is in the network, consumers
may choose their same provider.
5) If an adolescent consumer is outside the network, how will this affect him as far as
People living outside of the Sandhills Center catchment area whose Medicaid originates in a
Sandhills Center county will be assessed for their need to have Care Coordination intervention.
All individuals with I/DD issues will receive Care Coordination. Individuals with MH/SA
diagnoses will receive Care Coordination when Care Coordination is merited-for instance when
an adolescent transitioning from one level of care to another might need Care Coordination if
that adolescent is not receiving an enhanced service that has the Case Management component
embedded in the service definition.
6) What administrative things are in place to ensure that needed services are provided and
taken care of?
Our provider network is a big part of making sure the right services are available and provided to
the consumer. There will be an application process Sandhills Center will make available to
providers. To answer questions about housing and other needs, the infrastructure will hopefully
allow us to do more in considering those types of needs. Combining state and Medicaid dollars
should help in taking a more uniform approach in addressing these issues.
7) What things are in place to help monitor providers (i.e., technical assistance, ongoing
Our success largely depends on the success of our providers. Sandhills Center currently provides
trainings and technical assistance and will continue to do so for providers in our network. There
is a limit, however, to how far we can go if the provider is unable to meet and maintain necessary
criteria and standards.
8) How does waiver benefit providers?
Ability to change rates; makes it more feasible for providers to make services available.
9) How will a “closed” network affect “choice?”
Victoria Whitt responded by saying that a closed network will affect choice. Although there may
be fewer providers to choose from, the choice will come from “quality” providers. The closed
network does in fact limit the number of choices available, but the quality will be better.
10) Case managers currently working with consumers are (and need to be) people
consumers know and trust and love. What happens to that?
There are agencies who advocate for people. Consumers can continue to receive good quality
11) How difficult is it for providers to get out of the network?
Getting out of the network requires a certain amount of planning. There will be a process in
place to follow.
12) Substance abuse provider in Guilford County wanted to know why she received an
application in the mail from SHC and the application had a list of County options for
which Guilford County was not an option.
Network question- was advised to call the provider help desk.
13) Will provider billing change from MCO’s to Care Link? Also, how will a provider
Billing will be thru Provider Connect. They have training dates and provider orientation is
coming up that providers are encouraged to go to.
14) How does the waiver affect the relationship between the LME and CCNC (Community
Care of North Carolina)?
The LME works closely with CCNC to ensure both behavioral and physical health needs are
Questions pertaining to Treatment Plans/Assessments:
1) How will treatment plans be handled for children needing high-
levels of care?
Plans for a child will be different from those of an adult. Children have special needs and if case
management is needed, the provider will see that case management is received.
2) If a consumer no longer needs a service, will the funds be “lost” once services are
With the Innovation waiver, when an individual is terminated from a program, this allows
someone else to receive services; funds will not be lost.
3) Who is included in the assessment process? Are private insurance consumers included?
Is everybody re-assessed?
Everybody will be re-assessed, including private insurance consumers.
Tena Campbell added that the assessment is a “function.”
4) Are family members a part of the assessment?
Yes, family members are included in the assessment.
5) Are there limitations concerning consumers staying home alone?
The PCP will allow sitting down and discussing such issues, getting your input on what you
6) If an assessment is done to determine if “Johnny can pick up a pencil,” and Johnny picks
up the pencil (but with much difficulty), will the outcome be that Johnny is capable of this
activity? (The individual asking the question was concerned that the big picture might be
missed. Sometimes Johnny cannot pick up the pencil, or Johnny often has great difficulty
picking up the pencil.)
Other pieces of the evaluation will also be considered in the outcome…not just one aspect.
7) As of July 1, 2012, will SHC be the agency to review plans?
Questions Pertaining to Community Guides:
1) What are the qualifications for the Community Guide?
A Community Guide must be a high-school graduate.
2) How will the Community Guide work?
Staff will be hired and trained to operate as a Community Guide to help with the transition.
3) Who will the Community Guide be?
The Community Guide can be from any provider agency.
4) What are the qualifications for the “Community Guide?”
A high-school diploma is required. Tena stressed that the position is not long-term, but
temporary, to help through the transition.
5) Is the Community Guide like a CAP worker?
No, the Community Guide will be a separate service consumers may select.
6) What is the difference between the Care Coordinator and the Community Guide, as far
as consumer linkage and referral?
The Community Guide works on linking consumers with their natural support resources (family
7) Is there a monthly fee for the Community Guide? Is this a monthly contact?
A set procedure will be followed. The consumer/family has a choice of Community Guides.
The Community Guide service is not long-term, but is to help build the natural support.
8) How long does the Community Guide continue? Is there a certain length of time for this
It depends on the needs of the consumer. The Community Guide is authorized on an annual
basis. It may be needed only a short time, but it depends on the needs of the individual.
9) A question was asked in reference to who receives Community Guide.
With Innovations, determination will be made to see if there is a need for Community Guide.
Not everyone will need this service.
Questions pertaining to funding/fraud/appeals/hours:
1) How will capitated funds affect those on the waiting list?
The same allocation will be used. CAP/I/DD is based on the intensity of needs. Innovations will
consider how long the individual has been waiting.
2) How will rates be set…how often will it be done?
There will be few (if any) changes the first year. Rate-setting will be handled through an annual
process, although we haven’t been notified of the details. Rates will probably be set and
monitored within the annual pot of money.
3) Will state and federal dollars be kept separate?
Care Coordination will ensure that consumers are receiving needed services, whether funded by
the state or federal government. The money will be kept separate.
4) If someone is currently receiving state-funded case management, with no other services,
how will this be identified?
These services will transition over. Tena added that SHC is in the process of getting information
on all participants currently receiving services.
5) How are appeals handled?
The DMA has in place strict criteria for appeals. An internal process is followed to thoroughly
consider all aspects of an appeal, just as all Medicaid appeals are currently handled.
6) You said if a consumer does not use services for 30 days, services will be lost. How does
this affect a consumer who is in a facility for 30 days?
If services are not reinstated before the 30 days are up, services will terminate.
7) You mentioned that services were being abused. Please explain in what way there has
been abuse of services.
Unfortunately, fraud and abuse in the Medicaid system is definitely a problem, and has been
evident in lots of different areas. For example, an individual delivering personal service to
someone they know might not actually be qualified. Services may be documented but not
delivered, or delivered and not documented. SHC must enforce regulations through Program
Integrity which we will be monitoring. Fraud and abuse is a problem to providers and
consumers alike. Control helps cut down on fraud and abuse. SHC believes in training and
educating people—providers, consumers, and family members, to help prevent fraud and abuse.
8) A question was asked in reference to funds available for de-institutionalized consumers.
The maximum for any consumer is $135,000 per year.
9) Can relatives provide residential support for consumers living outside the home?
Relatives or guardians may provide services to consumers outside the home, if qualified.
10) Are in-home service hours for consumers limited to 40 per week?
If a consumer needs over 40 hours per week, Utilization Management must be notified and given
reasons why more hours are needed. If approved by U.M., more hours of service may be
provided, but a family member is limited to providing no more than 40 hours per week. If
service for additional hours is approved by U.M., they may be provided by another qualified
11) What happens to the funds if a consumer does not use the $135,000?
The $135,000 is the maximum that can be used for a consumer. Each consumer is not
automatically funded for the maximum amount.
12) Will hospitals bill Medicaid directly or will they bill the LME for hospitalizations
pertaining to a Mental Health or Substance Abuse patient?
As long as the member is from our catchment area the LME will be billed and pay for any
hospitalization, lab work, test, etc pertaining to Mental Health or Substance abuse. There are a
lot of discussions still going on as this is a complicated transition.
13) Are these programs that Medicaid pays for now?
Yes. Your service package stays the same.
14) Currently Medicaid does not pay for substance abuse, will Medicaid now pay?
ASMA determines the level of need and level of service.
15) What happens if a person wants meds but doesn’t have money for co-pay? Can they get
services or money?
Sandhills Center has wrap-around funds to cover that.
Questions Pertaining to the Waiting List:
1) If someone is on the waiting list, should the consumer/family member contact SHC with
any questions on this?
Yes, they should contact SHC.
2) How will waiver effect freeze on CAP slots?
We do not anticipate a change.
3) When a consumer is currently receiving services, will the use of the new
scale make available more services?
An assessment of behavioral issues will be conducted, and if it indicates the need for a higher
level of services, then more services may be provided.
Questions pertaining to family members/non family members as staff, etc..:
1) If a non-family member in the home is working with the consumer, can this continue?
More information is needed to fully answer this question. The answer may be yes, but keep in
mind it can be no more than 40 hours in one week.
2) A question was asked in reference to a family member providing services to a consumer
under the age of 18.
The individual cannot be a part of the natural support system. He/she may be a legal guardian
living outside of the home.
3) What about the family…what happens to the family?
We believe that the family is an important part of what happens. If you have specific issues, I
will be here afterwards to answer those questions for you. Al and Tena will go over much of
what your concerns are about.
4) How are families being notified of the changes of those that are in the facilities?
DMA distributes letter 10-15 days prior to the changes to their plans.
Questions pertaining to Members/Member needs:
1) If a consumer has received services for a long period of time, will they be able to keep
Services will be based on individual needs, which is the purpose of the new waiver. If the
individual continues to need the services, he/she will have access to these services.
If a consumer is mentally ill and receives case management services, will that continue?
Care Coordination for mental health is different from CAP I/DD. Care Coordinators are
assigned to consumers for short-episode mental health issues. Their goal is to get the consumers
connected to providers so they can receive needed services.
2) Question concerning non-Medicaid consumers.
If someone does not have Medicaid, they can go to the state services.
3) What if the consumer continues in crises?
If a consumer stays in crises, he/she may not be receiving the treatment/services needed. A Care
Coordinator will look into best practice modalities to consider the undergirding cause of the
crises. The Care Coordinator will make recommendations and watch for implementation of the
4) Will historical data be used in considering the needs of consumers?
Historical data will initially be relied on, as a new project like this would necessitate using such
information. The state must come to terms with management. This is about management in the
community, and what Sandhills Center is doing now shows we focus on “community.”
5) How will the determination be made concerning what services are needed for a
Decisions will be made through evaluations and an interview process.
6) How can we be sure the consumer is assessed correctly, allowing him/her to get services
If the family does not agree with the assessment, there will be a process to follow in order to
Victoria Whitt added that a firewall will be between Care Coordination and Utilization
Management which will be closely monitored.
7) Is this waiver going to impact the vision and dental with our kids Medicaid?
Your children’s vision and dental will stay the say. The 1915 (b) (c) Medicaid Waiver only
effects the Mental Health and Substance Abuse funding. Physical health is not affected by this
8) When is the hard copy of the handbook we received tonight effective?
The hard copy you received tonight is effective July 1, 2012. You can obtain a copy of the
current handbook by visiting our web site or by calling the customer service number that is listed
in your paper work.
9) Is there somewhere in the member handbook that shows what the different acronyms
Please put your name and address on the evaluation at the end with a note that you need a list.
We will be happy to mail you a list of the different acronyms and their meanings.
10) How can you tell when someone is on the verge of falling through the cracks or needs
There are 2 ways – When you call the 800 number the first question asked is “Is this a crisis?”
and those calls are passed to a clinician. Or our computers have a way of identifying who has a
high level of need. We can tell if someone is in and out of the hospital and intervene if we see
they are in crisis. People can always call crisis line and mobile team will come to them wherever
11) Does this only mean Medicaid? Does this help people with Medicare too?
No, this is only for Behavioral Health services, which means Medicaid only. We do not manage
Medicare, only Medicaid and State funds.
12) Is EPSTD part of this program?
That program is for children under 21 months. Yes, we will follow those guidelines.
13) Are Comp Ed classes still covered?
No, you cannot use waiver funds to go to Comp Ed classes. Community College classes are
covered, but they must be inclusive classes, not segregated. You can do day supports in
facilities that are licensed to do so.
14) Can I use 1-on-1 support at a Community College?
Yes, in an inclusive setting.
1) Families are not represented at the forum; how can they be educated on the changes?
Providers are at the forums and will help educate the consumers. Any questions may also be
addressed to Sandhills Center’s Customer Service Department, where staff will help answer
Ron Huber added that information was sent out to many different organizations to notify the
community of the forums: DSS, schools, etc. Ron reminded everyone about the toll-free
number to call for assistance.
2) Will service definitions remain the same?
3) Will a consumer be able to change options: go from self-directed to other?
Yes, the change will be handled through a planning process.
4) How is the risk pool handled?
The state adds funds to the risk pool.
5) We’ve heard the benefits of the new Medicaid Waiver. What are some of the things
included in the “down-side” of the Waiver?
The closed network might be viewed by some as a negative side to the waiver. The LME will
also have more control, and will be at risk due to use of the capitated model, leaving the
community fully at risk. There are changes with the Waiver, and people may be concerned that
there’s too much change. Having said this, I believe not doing this is more dangerous than doing
it. The state knows something has to happen. It could have been decided by the state that they
give responsibility to private entities, such as Blue Cross, etc., in which case the savings would
have gone to the stockholders rather than the state. The LME’s are under pressure to make this
work, otherwise the entire system will suffer.
6) A question was asked in reference to transitioning consumers who are residing in facility
More information from Raleigh is needed to answer this question.
The DMA wants information from across the state on those residing seven days or more in
facilities that are not Community- home based. There are strict criteria on residing in
institutional settings, and we currently don’t have all the details on this issue.
7) In reference to the Supports Intensity Scale (SIS), will it vary from LME to LME?
Standardized tools will be used by all LME’s.