The document provides an overview and update from the NC Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services at their annual NC Provider's Council Conference. Key points include: 1) The department's goal to present a comprehensive spending plan for fiscal year 2020 funds to managed care organizations by the end of February 2019. 2) An overview of the department's budget, which totals $565 million from state, federal, and other sources. 3) Details on the department's "Healthy Opportunities" initiative to address social determinants of health like housing, food, transportation, and safety. 4) An introduction to "Tailored Plans

1. NC Department of Health and Human Services
Division of Mental Health, Developmental Disabilities,
and Substance Abuse Services
NC Provider’s Council Conference
Lisa Haire, Assistant Director, DMHDDSAS
Kody Kinsley, Deputy Secretary
January 15, 2019

2. Overview
1. Valentines Day Goals – Single Stream Funding
2. Overview Budget Landscape
3. 2019 “Healthy Opportunities”
4. Medicaid Transformation - Tailored Plans
5. Questions

3. Valentines Day 2019 Goal
Valentines Day Goal:
Present a comprehensive spend plan for SFY 2020
to LME/MCOs (and our leadership) for review,
feedback, and finalization by end of the February
2019.

4. Valentines Day Goal –
Working Backwards
Strategies:
1. Problem-Oriented Spending – Sources/Uses, Dep’t Wide
View, Coordinate/Compliment, Biennium Budget!
2. Block grant spend plan – Good Data, Timing, Systems, Spend
Strategy, Routine Reports.
3. Single Stream Fund / Block Grant Re-Balance
4. Narrow and Deep or Wide and Shallow? –Service Arrays;
State funds cover who?

5. 4.2. Valentines Day Goal –
Working Backwards
Strategies, continued:
5. Quality Measures / Data – Cost Controls & Disease
Controls; Incentivize Improvement; Unmet Need
6. Professionalized Regulator – Form Must Align to Function --
Skills, Organization, Recruitment
7. How we work – Accountability, Badgeless, Constant
Communication, Personal, Patients/People, Privilege.

6. Federal Grants,
$89.3 , 15.8%
Other Receipts,
$51.5 , 9.0%
State, $424.8 ,
75.2%
SFY 18 Sources of Funds (Millions)
DMHDDSAS Budget Sources Overview
Total: $565 million
Other Receipts: Includes multiple items such as transfers – details on slide 12

7. DMHDDSAS Budget Sources State
Total: $424.8 million
Single Stream,
$229.8
State Categorical,
$39.4
Carryforwards, $37.8
ADATC, $36.1
DMA SSF Transfer,
$30.0
TCLI, $13.9
Housing, $3.2
TBI, $1.9
SFY 18 Sources – State (Millions)
“State Categorical”
• Community
Based Crisis
• Group Homes
• IDD Consultation
• RHA Health
Services

8. DMHDDSAS Budget Sources Other Receipts
Total: $51.5 million
“Other” Examples:
• Licensing Fees
• Provider Match
• DPH Transfer
Legislative
Carryforward, $33.6
Other, $5.8
Central Admin
Transfer, $3.8
DPI Transfer, $3.0
Encumbered
Carryforward, $2.4
Dix Funds
Transfer, $2.0
FDA - NC
Tobacco,
$1.0
TBI, $0.2
SFY 18 Sources - Other Receipts (Millions)

9. UCR, $264.7 ,
46.8%
Non-UCR, $239.2 ,
42.3%
Contract, $37.4 ,
6.6%
Salary and Benefits,
$23.6 , 4.2%
Admin, $0.1 , 0.02%
SFY 18 Expenditures - Uses by “How” (Millions)
DMHDDSAS Budget Uses Overview
Total: $565 million
89.2% through the
LME/MCOs

10. Healthy
Opportunities
• All North Carolinians should have the opportunity
for health. Access to high-quality medical care is
critical.
• Research shows up to 80 percent of a person’s
health is determined by social and environmental
factors and the behaviors that emerge as a result.
DHHS is focusing on tackling these fundamental
drivers of health.
• To meet our mission of improving the health,
safety and well-being of all North Carolinians while
being good stewards of resources, DHHS is
addressing the conditions in which people live that
directly impact health, known as “social
determinants of health,” or SDOH.
• Our initial focus is on housing stability, food
security, transportation access and interpersonal
safety.

11. Healthy Opportunities Strategies
• Creating an interactive statewide map of SDOH indicators that can guide community
investment and prioritize resources.
• Developing a set of standardized screening questions to identify and assist patients with
unmet health-related resource needs.
• Building a statewide resource platform to connect those with an identified need to
community resources.
• Incorporating SDOH strategies throughout the Medicaid 1115 wavier.
• Developing public-private pilots that knit together health care and community services,
with the goal of incorporating evidence-based interventions into the state Medicaid
program that address health factors related to SDOH.
• Building an infrastructure to develop and support a Community Health Worker Initiative.
• Examining better ways to streamline cross-enrollment in existing key benefit programs.

12. Overview of Tailored Plans
Overview of Tailored Plans
 What is a Tailored Plan (TP)?
 Overview of Eligible Population
 How Enrollment Works
 Benefits
 Care Management
 Key Design Questions on TP Protections
TP Design and Stakeholder Engagement
 TP Design and Launch Timeline
 Opportunities to Engage
12

13. What is a Tailored Plan (TP)?
TPs are designed for those with significant behavioral health (BH) needs
and intellectual/developmental disabilities (I/DDs)
TPs will also serve other special populations, including Innovations and
Traumatic Brain Injury (TBI) waiver enrollees and waitlist members
TP contracts will be regional, not statewide
LME-MCOs are the only entities that may hold a TP contract during the first
four years; after the first four years, any non-profit PHP may also bid for
and operate a TP
LME-MCOs operating TPs must contract with an entity that holds a prepaid
health plan (PHP) license and that covers the same services that must be
covered under a standard benefit plan contract
TPs will manage State-funded behavioral health, I/DD, and TBI services for
the uninsured and underinsured
North Carolina will launch specialized managed care plans, called Tailored Plans, starting in 2021;
design of these plans is just beginning
Key Features of Tailored Plans:
13

14. Key Aspects of TPs:
Overview of Eligible Population
Qualifying I/DD diagnosis
Innovations and TBI Waiver enrollees and those on waitlists
Qualifying Serious Mental Illness (SMI) or Serious Emotional Disturbance (SED)
diagnosis who have used an enhanced service,
Those with two or more psychiatric inpatient stays or readmissions within 18 months
Qualifying Substance Use Disorder (SUD) diagnosis and who have used an enhanced service
Medicaid enrollees requiring TP-only benefits
Transition to Community Living Initiative (TCLI) enrollees
Children with complex needs settlement population
Children ages 0-3 years with, or at risk for, I/DDs who meet eligibility criteria
Children involved with the Division of Juvenile Justice of the Department of Public Safety and
Delinquency Prevention Programs who meet eligibility criteria
NC Health Choice enrollees who meet eligibility criteria
TP Populations:
14

15. How Plan Enrollment Works
There are two ways in which an individual will be identified for enrollment in a TP:
DHHS will review several sources of data to determine if
an individual is TP-eligible:
• Medicaid claims and encounter data
• State-funded Behavioral Health (BH),
Intellectual/Developmental Disabilities (I/DD), and
Traumatic Brain Injury (TBI) data
• Innovations and TBI waiver enrollment and waitlists
These individuals will remain in their current delivery
system (generally Fee-for-Service/LME-MCO) until TPs
launch. When TPs launch, these individuals will be
defaulted into TPs, but have the option to enroll in a SP.
DHHS Data Review
Individuals can self-identify as potentially TP-eligible at
any time:
• Individuals may request an assessment from a
qualified provider to determine if their health
needs meet TP eligibility criteria
• A qualified provider can also submit an assessment
form for enrollees who need a TP-only service
• DHHS reviews and provides approval or denial of
request within 3-5 days, or 48 hours for an
expedited request
Self-Identification
15
Each year, TP enrollees will be re-enrolled in their current plan, unless they have meet both of the following criteria:
• Have Serious Mental Illness (SMI) or Substance Use Disorder (SUD) diagnosis, and
• Have not used any Medicaid or State-funded behavioral health service in the 24 months besides outpatient
therapy or medication management
Enrollees who meet these criteria will be transitioned to a Standard Plan (SP), but will have the opportunity to obtain an
assessment to move back to a TP at any time.

16. Physical health services
Pharmacy services
State plan long-term services and supports (LTSS), such as personal care, private duty nursing,
or home health services
Full range of behavioral health services ranging from outpatient therapy
to residential and inpatient treatment
New SUD residential treatment and withdrawal services
Intermediate care facilities for individuals with intellectual disabilities (ICF/IID)*
1915(b)(3) waiver services*
Innovations waiver services for waiver enrollees*
TBI waiver services for waiver enrollees*
State-funded behavioral health, I/DD, and TBI services for the uninsured and underinsured*
TPs will provide comprehensive benefits, including physical health, LTSS, pharmacy, and a more
robust behavioral health, I/DD, and TBI benefit package than Standard Plans
TP Benefits Include:
Plan Benefits
16
Note: Dual eligible enrollees will receive behavioral health, I/DD, and TBI services through the TP and other Medicaid services through FFS
*Services will only be offered through TPs; in addition, certain high-intensity behavioral health services, including some of the new SUD services, will only
be offered through TPs

17. Building Responsive Care Management
All BH I/DD TP enrollees will be eligible for care management
Every enrollee will have a single assigned care manager who will be
responsible for ensuring integrated and coordinated physical health,
behavioral health, I/DD, and TBI services
BH I/DD TP care management will be more holistic and intensive than care
coordination currently offered by LME-MCOs. It will be available for longer
periods of time than care coordination and will have a greater focus on
transitions of care and population health management
Care management will be community-based to the maximum extent possible
 BH I/DD TPs will be required to contract with tier 3 or 4 advanced medical
homes and community-based care management agencies to provide local
care management.
 BH I/DD TPs will only be allowed to provide those services in house when
DHHS determines that capacity of advanced medical homes and
community-based care management agencies is a limiting factor.
BH I/DD TPs will offer care management that
will align with the following key principles:
17

18. Key Design Questions on TP Protections
DHHS is working to design responsive TPs that consider the varied and specialized needs
of their populations, and will be seeking stakeholder input on how to best ensure
enrollee protections are in place, and that enrollees have a positive experience.
Developing an
Effective Service
Authorization and
Appeals Process
Ensuring
Smooth
Transitions
Ensuring Consumer
Representation in TP
Operations
TPs will be required to regularly engage and
consult with consumer and family representatives.
DHHS will be seeking ways to ensure this
engagement is meaningful and responsive.
Enrollees may need to transition
between Medicaid fee-for-service, TPs
and standard plans depending on
service needs.
DHHS will be seeking input on
requirements to promote continuity of
both physical and BH services when
these transitions occur.
An effective service authorization and
appeals process for approval and denial
of benefits or services is central to
timely access to critical care.
DHHS will seek feedback on this
process to ensure it meets the unique
needs of TP enrollees.
18

19. TP Design and Launch Timeline
SPs launch in remaining
regions;
DHHS releases BH I/DD
TP RFA
(tentative)
DHHS awards BH
I/DD TP contracts
(tentative)
Feb.
2019
DHHS issues SP
contracts
Nov.
2019
SPs launch in initial
regions
Feb.
2020
July
2021
BH I/DD TPs
launch
Aug.
2018
DHHS released
SP RFP
SP implementation planning
(8/2018-2/2020)
BH I/DD TP design
(8/2018-2/2020)
BH I/DD TP implementation planning
(2/2020-7/2021)
Jan.
2019
Begin implementing IMD
waiver for SUD
(i.e., receiving Medicaid
reimbursement for services
delivered in IMDs to
individuals with SUD)
May
2020
Until early 2020, DHHS will be conducting intensive planning for both Standard Plans (SPs) and TPs.
After SPs launch, DHHS will continue implementation planning for TPs.
19
(tentative)

20. QUESTIONS??