This webinar is about the Medicaid Transformation process currently happening in NC. It will review trends in Medicaid reform on a national level, the history of Medicaid reform in NC, and provide tips to family members and self-advocates about how to effectively engage the system.

1. Medicaid Transformation
- National Perspective
- North Carolina View
- Understanding It
- Educating/Advocating to effectively
shape it
Barbara Brent, NADDDS
First In Families of NC staff:
(Interim Facilitators Jan.-March 2016)
Kelly Friedlander, Local Facilitator
NC Stakeholder Engagement Group
info@ncseg.com
919-330-0777, ncseg.com

2. What’s Happening with Medicaid?
The way Medicaid and
Medicaid-funded
programs are managed is
changing in North
Carolina and throughout
the US.
What’s happening
nationally?
What’s happening in NC?
How can you advocate to
effectively shape our new
system?

4. Medicaid: A Growing Piece of the Puzzle for
individuals needing long term support services
(LTSS) or who have complex support needs

5. National Trends in Response
to Medicaid Transformation
States are finding ways to address demographic realities and
move forward to support person centered and family centered
supports with increased flexibility targeted to a good life in the
community for both individuals with disabilities and their family
members.
•Supporting Families
•Relationship-based supports, housing innovations & partnerships
•Employment and other meaningful engagement services in the
community
•More and better in home supports and services (new HCBS defs)
•Capped support (and comprehensive) waivers
•High intensity support coordination/case management with
understanding of community, families & individuals

6. National Trends in Response to
Medicaid Transformation (cont.)
Managed Care is growing, particularly in behavioral health and
acute care.
There is some growth of the inclusion of I/DD and physical
disabilities, particularly in home and community based, long
term services and supports beyond medical and recovery.

7. A Common Goal: Supporting People
to have Real, Meaningful Lives
Growing national consensus on:
•Person – and family – centered approaches to support;
•Recognition that people with disabilities are not one
dimensional;
•Recognition that supports must consider the whole person,
and
•Measuring outcomes is key to continuous improvement

8. Besides Being a Valued Goal - it is the Law
The Centers for Medicare & Medicaid Services (CMS), which funds most of the services
(states match dollars) passed new, final rules in January 2014 for Home and
Community-Based Services (HCBS). These rules require HCBS settings to provide
opportunities for participants to engage in community life, have access to the
community, control their personal resources, and seek employment and work in
competitive settings. The purpose is to enhance the quality of HCBS, provide
additional protections to participants, and ensure that individuals receiving services
through HCBS programs have full access to the benefits of community living.
HCBS Sets:
● What is NOT community
● What is likely not community
● What is community
Person-centered planning
● Specifies requirements for planning (both process and content)
Many states have much work to do! Day services? Residential? What changes need to be
made in managed care?
The law applies to HCBS services
in managed care and the new
proposed managed care rules offer
even more protections.

9. States are Exploring Many Potential Paths

10. Integration is welcomed;
but what does it mean?
Integrated, person-centered, holistic approaches to health and
support services are growing…but the terms themselves may vary
in meaning:
Integration of Medicare and Medicaid
● Many individuals with complex health and social support needs are
eligible for both Medicare and Medicaid.
Integration of health care, mental health and substance use services
and long term services and supports
● Many systems of care (both at the state and local levels) are
recognizing that understating the whole person can impact
outcomes.
Integration in the Community
● Individuals, regardless of their support needs, should be supported
in and be supported to contribute within their communities.
And the second integration (health, mental health, substance abuse)
is gaining more traction than I/DD or some physical disability communities

11. What is needed for Managed Care
to be Successful?
Focus on Employment, In-Home
Supports and Services AND Family
Support:
• Support Families to Envision a Good
Life
• Support Family and Peer Networks
• Provide information and Navigation
• Design supports to be flexible and
responsible
• Understand the impact on policies for
ALL families.

12. And Managed Care entities need to focus on…
The Individual will achieve self-determination,
interdependence, productivity, integration, and
inclusion in all facets of community life
Families will be supported in ways that maximize
their capacity, strengths, and unique abilities to best
nurture, love and support all individual members to
achieve their goals.
“A Good Life for All”

13. MCOs Must Learn and Understand the
implications related to:
Services for people with I/DD can start in
early childhood and last for a lifetime,
unlike services for people that are seniors,
and while some services are intermittent
and intensive, many are ongoing.
This makes service planning and cost
planning unique compared to MCO
planning for other populations. Services
are not primarily medical over a lifetime.
Does everyone have to live with
their family?
No…it means we must:
• Focus on supports for those
living in the family home where
it is working and it is what
people want
• Maximize an array of support
strategies beyond only
depending on 24 hour
residential models.
• Recognize the contribution and
importance of family members
in the lives of members with a
disability that live outside of the
family home.

14. Assistance is needed in Developing and
Integrating Supports and Services
Person or family
resources, abilities,
strengths,
characteristics
Family, friends,
neighbors, co-workers,
community members,
church members.
Disability Services,
Special Education
Medicaid, Housing,
Food Stamps,
Vocational Rehab (VR)
iPad, smart phone apps,
remote monitoring,
cognitive accessibility,
adaptive equipment
School, businesses,
Church/faith-based,
public transportation,
parks and recreation

15. What rings true for I/DD often is true for
people with MH needs (and vice versa)
Individuals with Mental Health needs
The language is sometimes different but the emerging trends
are quite similar:
• Person-centered approaches to care and support
• Improving options when individuals need residential support
• Increasing home and community-based options
• Increasing relationship-based options; including peers
• Improving quality and availability of crisis supports
• Ongoing care coordination/support
Think support coordination
and think employment!

16. States are Using More than Managed
Care in their Medicaid change approach:
Existing and Emerging Tools
Medicaid has many options states are exploring, some old,
some new.
• Section 1915 (c) HCBS Waivers
• Section 1915 (i) HCBS as a State Plan Options
• Section 1915 (k) Community First Choice Option Health Homes
• Managed Care Authorities
• Comprehensive demonstration programs (1115s)

17. Managed Care Long Term Support
Services (LTSS) across the U.S.
Arizona 1115 (DDD is MCO) includes
HCBS, medical and behavioral health-
govt
Michigan (b/c) BH and IDD –gov’t
Wisconsin (b/c) all pops-both gov’t and
private- but change is in the wind
Kansas -all pops but behavioral health
carve out- did not go smoothly with I/DD
and significant delays - 1115, private
MCOs
New Hampshire-1115 private MCOs-
I/DD significant delays-will roll out at
some point
Texas 1115- private all pops, DD carved
out but will pilot with gov’t soon
In planning states
• Tennessee has had other
populations for years, but I/DD to
roll out soon with a focus on in
home supports and employment
• Iowa about to roll out all
populations but CMS delay
• Illinois in planning stages
• New York (b/c) pre implementation
• Louisiana and some other states in
exploration
And, of course, North Carolina!

18. Some exceptions to watch/learn from:
• Alabama is being blocked;
• Iowa- nobody wants to go to managed care;
• Michigan- starting health homes but not for IDD/MH/SUD
• New Jersey initially carving out most people and keeping
1915 c;
• Pennsylvania- more than a little exciting!
• Virginia carving out I/DD
• Arizona: some demonstrations with behavioral health
and acute (health)

19. States must support providers during any
transformation
Challenges Facing Provider Agencies
• More formal & complex contracting processes
• More complex billing practices – clean claims,
encounters, codes – providers need assistance
• Can have more licensure/credentialing requirements –
even for services/supports that are non-clinical in nature
• Need better understanding of prior authorization and
related constructs
• Need for more sophisticated data and analytic capacity –
for payment, to make a case of increased rates, incentive
payments or to show increased authorization needs for
people.
• More extensive contract requirements
• Operational changes to meet MCO contractual
provisions – and working with systems partners to
ensure person-centered outcomes and requirements

20. What about North Carolina?

21. NC House Bill (HB) 372:
Medicaid Transformation & Reorganization
● A brief History: How did we get
here?
● The Details: What does HB 372
do?
● The Timeline: When will this
happen? (this Bill not yet
approved)
● The Opportunity: How can
advocates shape the future
system?
NC SEG Member Matt Potter
speaks at the Medicaid Reform
Advisory Group meeting in
January 2014

22. February 2013
DHHS issues a Request For Information (RFI) asking for input on
Medicaid system-this means people (mainly companies were
asked to share their ideas and concerns)
Mid-March 2013
DHHS receives approximately 160 responses to RFI
April 2013
Gov. Pat McCrory and Secretary Wos unveil “Partnership for a
Healthy North Carolina”
● Goal was to have new system in place by July 2015
May 2013
Secretary Wos tours the state to gather feedback on the new plan
The History: How Did We Get Here?

23. 2013 Legislative Session
Legislature does not agree on a Medicaid Reform plan.
November 2014
Medicaid Reform Advisory Group formed
February 27, 2014
Medicaid Reform Advisory Group presents their Medicaid plan
2014 Legislative Session
Legislature does not agree on a Medicaid Reform plan.
House & Senate have very different
visions of Medicaid’s future
The History: How Did We Get Here?

24. The History: How Did We Get Here?
2015 Legislative Session
● Budget negotiations held up for months
● Budget finalized close to 12 weeks after state mandated deadline of
July 1st
● House Bill 372
● Filed March 26, 2015
● Passed on September 22, 2015
● The Senate
● 33 voted it for it and 15 voted against it
● less than five minutes of debate--this is fast!!!
● The House
● 65 for - 40 against
● One hour of debate - also very fast!!!
● Signed by Gov. Pat McCrory on September 23, 2015

25. The purpose behind HB 372
The theme of HB
372 is to reform
Medicaid by
moving it from a
fee-for-service
model, to Managed
Care, primarily to
control costs.

26. The Details: What structure is
proposed in HB 372?
• Combines the Senate’s and House’s preferred
plans: providers can form their own managed care
regional entities.
• The state will solicit bids from three
commercial entities to provide care across the
state, with three to five year contracts to stagger
implementation.
• Up to 10 contracts will be awarded to regional,
Provider Led Entities (PLEs).
• The state will be divided into 6 care regions.
• At least two providers will offer care in each
region, with the idea to give Medicaid beneficiaries
choice and create some competition between
providers.
• The bill calls for the creation of a Division of
Health Benefits to replace DHHS’ Division of
Medical Assistance, the part of the department
that currently runs Medicaid.

27. The new managed care entities
will serve Medicaid-eligible
people’s acute care (physical
health) needs
Exceptions:
• Dual Eligibles - people who
are eligible for both Medicaid
and Medicare, the health care
program for seniors and
people with disabilities.
• Dental care will continue to be
provided on a fee-for-service
basis.
For at least the next four years
individuals receiving behavioral
health services (MH or IDD or
SUD) will continue to receive
their care through existing LME-
MCOs.
The Details: Who is covered by HB 372 ?

28. The Timeline: When Will This Happen?
● DHHS to report to Legislative Oversight Committee on Medicaid
and Health Choice due on March 1, 2016.
● Update! As of today…
● Bill requires the state send the detailed plan to the Center for
Medicaid and Medicare Services (CMS) by June 2016. It is
referred to as the 1115 waiver.
● Public Comment period (CMS requires at least 2 events) will
start ~ March 15th;
● CMS approval will most likely take at least 18 months, and
possibly two years. Some parts of the waiver may approve
quickly, others can take more time. The bigger the changes, the
longer it can take.

29. The Timeline: When Will This Happen?
● Managed care contracts will begin 18 months (or more) after CMS
approval and when the state feels confident all is a “go”.
● LME-MCOs and their provision of all behavioral health services are
“carved out” (not included) for at least four years after managed
care contracts are implemented, then possibly for another four year
extension.
● Behavioral Health Services= public mental health, intellectual/
developmental disability and substance use disorder services
Public comment and input may alter the final design of the 1115
Other “Wild Card” Factors: Elections and Medicaid Expansion
Bottom Line: It’s Going To Be A While Before All is Worked Out

30. ● Various, powerful stakeholders
will be at the table
● Private Managed-Care
Organizations
● Elected Officials
● Hospital/Medical
Associations
● Senators & Representatives
● Healthcare Non-Profits
● Associations and Providers
AND
YOU: cross disability
consumers and family
members
The Opportunity: What Can Advocates Do?
“We have an opportunity to make a
significant change in the future of health
care. If we get it right – if we get it right
together – then we’ll have a chance to look
back and say, ‘This has made a difference.’”
- Dave Richard, Deputy Secretary
Division of Medical Assistance

31. A Challenge for Advocates
● Disability populations often silo-ed
in their advocacy/education efforts
and this can be particularly true in
cross disability efforts;
● Consumers and family members
are under-represented in the
policymaking process;
● When invited, consumer and family
members are often:
● Not adequately prepared
● Do not have a common set of
agreed upon principles or
values to educate and
advocate for.

32. Despite the Challenge
The system is rapidly changing and the involvement of consumers
and families is more important than ever.
How can we have a greater impact together rather than acting in
silos?

33. About the NC SEG
A backbone entity with staff and a
specific set of skills to serve the entire
SEG initiative and coordinate
participating organizations and
agencies.
• Cross-disability advocacy initiative
• Focusing on shaping long-term
support and service through
meaningful engagement and
dialogue with policymakers
• Consists solely of individuals
receiving services and their family
members
• Works in collaboration with DHHS

34. Common Agenda
All participants have a common
agenda for change including a
shared understanding of the
problem and a joint approach to
solving it through agreed upon
actions.
Outcomes & Expectations
Report
● 5 Outcomes
● 12 Expectations

35. Common Agenda: 5 Outcomes of a
Successful North Carolina MLTSS System
1. All eligible people receive services and supports they
require - no waiting list
2. Everyone works in integrated community employment at
competitive wages, with the supports necessary to be
successful
3. Everyone is able to develop personal and financial assets
4. Everyone lives inclusively in the community, in housing
that is not segregated by disability, with people of their
choice, and with active participation in his/her community
5. The system is continuously accountable (achieves the
desired outcomes and is transparent to the public) by
involving consumers and families in its design,
development, oversight, and evaluation

36. Common Progress Measures
● Collecting data and
measuring results
consistently across all the
participants’ disability areas
ensures alignment and
accountability.
Outcomes & Expectations
Scorecard
A tool organizations or
individuals can use to see how
well a policy aligns with the NC
SEG’s Outcomes &
Expectations for MLTSS

37. Mutually Reinforcing Activities
A plan of action that outlines and
coordinates complementary
activities by each participant.
● Examples:
● Increasing consumer and family
members participation in
government
● Writing letters and presenting
Outcomes & Expectations Report to
Secretary Brajer
● Presenting at the Medicaid Reform
Advisory Committee Meeting
● Providing written comments on
rules, regulations, etc.
● Meeting with elected officials
“Spending the afternoon with the Stakeholder
Engagement Group was an invaluable
experience for me. While their members got a
chance to sharpen their legislative advocacy
skills, I got an opportunity to hear directly
about what we need to do to make life more
livable for our citizens with disabilities.”
– Senator Jeff Jackson, District 37

38. Communication
• Open, communication among many players to build trust, assure
mutual objectives, and assist others in understanding why the
Outcomes and Expectations will make a positive difference for
multiple organizations and groups.
• SEG members promote the Outcomes & Expectations among all
member’s networks

39. Who agrees?
● The “NC Outcomes and Expectations for Managed Long Term
Services and Supports Report” has been endorsed by:
• NC Council on
Developmental
Disabilities
• Oxford House
• The Developmental
Disabilities Consortium
• First In Families of NC
• The Power of The
Dream
• Disability Rights NC
• State Consumer & Family
Advisory Committee
• NC Consumer Advocacy,
Networking and Support
Organization
• Smokey Consumer &
Family Advisory
Committee – Central
Region
• NC Substance Use
Disorder Federation
• Alcohol & Drug
Council of NC
• NC Statewide
Independent Living
Council
• National Alliance on
Mental Illness NC

40. Advocacy and Education Moving Forward
Align your personal/group advocacy messaging with a common voice
for the greatest impact
● NC Outcomes and Expectations for Managed Long Term
Services and Supports Report
● The Coalition “3 Goals” white paper aligns well with the SEG
Outcomes and Expectations
Educate other individuals with disabilities and their family members so
they can more effectively engage in systems change activities
● Materials posted on NCSEG.com
● The NC SEG can provide informational presentations to
various groups/organizations

41. Advocacy Moving Forward
• Stay involved in current advocacy work
• LME-MCOs, task forces, workgroups, etc.
• CFACs
• The Coalition
• The DD Consortium; Mental Health Coalition; Substance Use
Disorder Federation and their member organizations
• Be specific; why the Outcomes and Expectations; provide
examples; show why they matter; pick one that makes a difference
to you or that the group you are speaking with is passionate about.

42. Stay Active
Managed Care won’t be built in a day...
• Although LME mergers on hold for now; and LMEs (& all
behavioral health services) “carved out” for next 4-8 years,
stakeholders still need to pay attention:
• Attend Listening Sessions for Innovations Waiver
• Learn more about the new DD Caucus being set up in the
General Assembly
• Learn how people’s Health issues are impacted by system
change and how to influence

43. Whether in the new system or now, there are many
additional specific activities SEG and others can do to
help?
What can you take on as your issue(s)? For
example:
• “Medical necessity” for LTSS should not be based solely on THE score or THE uniform
assessment and instead includes a review of family context- - a person could have the same
score but live in a home with a single parent with five other siblings. How can the SEG and
others educate/advocate for best practices/?
• Generally managed care organizations have worked short term with people. Families are in
there for a lifetime. How can you help them design the program and training with this in
mind?
• Families must help write or at a minimum, independently review policies. People with disabilities
and families must help provide training to MCO staff, providers, case managers/support
coordinators- especially in the shift to managed care.
• Initial contact with system (i.e. intake process) should take place in the person and/or family’s
home. That is the expectation in HCBS/LTSS but not currently uniform practice.
• Influence legislation….

44. Get READY to Vote
●Make your voice heard.
●Your local elections are very important. These are the
people who will be making decisions for NC.
●Research your candidates, talk with them, ask
questions!
●Then hold them accountable!
●Learn about how the NC Voter ID laws might impact
you or your family members: http://voterid.nc.gov/
●Voter registrations due 25 days before the election
●For more on registering to vote (deadline passed for
March 15th primary) http://ncvotered.com/register/

45. Get Out and Vote
● Vote in the General Primary on March 15th
● The General Primary is where you can vote for Presidential
Candidates in your party. Other referendums will also be on
the ballot.
● Vote in the Congressional Election on June 7th
● Due to redistricting Congressional Elections have been
postponed until June 7th
● For more information on voting accommodations visit:
http://www.disabilityrightsnc.org/voting
● To find your polling location: http://ncvoterguide.org/answers/
● A comprehensive view of recent voting changes and what they
mean to you:
● http://www.wral.com/q-a-2016-changes-to-congressional-
districts-and-other-elections/15406485/

46. Stay tuned for: Stakeholder Toolbox
The NC SEG toolbox will contain
useful information for advocates
including:
-the basics of managed care;
-what stakeholders should expect
from:
State agencies
MCOs
-suggestions for Stakeholder
engagement in policies, procedures
and oversight initially in systems
design;
-ongoing tips, tools, report cards,
measures, design strategies,
readiness, contracts, policies, network
development and adequacy,
innovation and leadership.
Sign up at www.ncseg.org to be
notified when tools are added!

47. “I'm amazed by the hard work, results and
vision of our group. The NC SEG brought
individually marginalized stakeholders
together and demonstrated that together we
have a powerful voice throughout our state.
We have the experience, skills, empathy and
common sense needed to help inform
policymakers about what is needed to
achieve our common goals. We're a lovely
group of people to spend the day with -
and we vote.”
- Jackie Darling, NC SEG Member

48. Questions?
● Share our materials with others. Educational materials can be
found on our website at www.ncseg.com/stakeholder-tools.html
● Join our mailing list at www.NCSEG.com
● Like us on Facebook at www.facebook.com/NCSEG
● Have a group you are affiliated with endorse our Outcomes &
Expectations Report; e-mail info@ncseg.com for information
● Collaborate with us in some other way! Contact the local
facilitator at info@ncseg.com to share your ideas