Quality in Managed Long-Term Services and Supports Programs. Appendix D. North Carolina's 1915(b)/(c) Medicaid Waiver for Mental HEALTH/ Developmental DISABILITIES/SUBSTANCE Abuse Services


  Element     Description  
MLTSS Program North Carolina 1915(b)/(c) Medicaid Waiver for MH/DD/SAS
Lead Agency Department of Health and Human Services (DHHS), Division of Medical Assistance (DMA)
Medicaid Authority 1915(b)/(c)
Inception 2005
Year LTSS Added An MLTSS program from inception.
Groups Enrolled Persons with Mental Illness, SA Disorders and IDD.
# Enrolled 1,426,398--total number enrolled.
84,861--using MH, DD or SAS (breakout by disability group currently not available).
  1. State Quality Oversight Infrastructure
For quality oversight, North Carolina's Waiver relies on the Behavioral Health Unit in the DMA and the staff responsible for services for individuals with intellectual and/or DD housed in the operating agency, the DMH/DD/SAS. DMA's Behavioral Health Unit has 4 contract managers at the state level that oversee the operations and quality of 11 LME-MCOs. These contract managers are also responsible for staffing an IMT that meets at least quarterly to review Performance Indicators, reports and data, and timeliness of submission of reports from the LME-MCOs. The DMA contract managers lead the IMT, in collaboration with the operating agency for intellectual and DD services, DMH/DD/SAS. The IMT includes representatives from quality, finance, information systems and clinical services from DMA, DMH/DD/SAS and from the LME-MCO.

The DMA Behavioral Health unit also has 1 FTE that is dedicated to quality at the state level. This staff member oversees the contract for the EQRO, the quality strategy and all quality reporting.

Additionally, there is state level stakeholder oversight provided by the DWAC. This is an advisory body to DHHS that provides input and consultation over implementation and operational phases of the 1915(b)/(c) Medicaid waivers and the ongoing LME-MCO operations (Medicaid managed care, Innovations and LME operations).

  1. State IT Infrastructure for Supporting Quality Oversight
The state is currently revamping its IT system to meet the needs of operating a managed care system and requires each LME-MCO to make all collected data available to the state and, upon request, to CMS. Until the state's MMIS is revised to accept and process encounter data, the LME-MCO must submit electronic records of encounters to DMA on an as-needed basis for rate-setting, QA, waiver amendments, renewals, EQRO activities and other activities as required by DMA. The state expects each LME-MCO to submit encounter reports that include all capitated data, for all services rendered under the (b) and (c) waivers.
  1. MCO Quality Oversight Responsibilities
LME-MCOs are required to employ a full-time QM Director with appropriate qualifications including QM experience and managed care experience or experience in MH, DD and SA care.

The LME-MCOs also monitor services provided by network providers. This includes conducting peer review activities such as identification of practices that do not meet standards, recommending corrective actions and monitoring provider corrective actions.

LME-MCOs are also required to verify that services reimbursed by Medicaid were actually furnished to enrollees by a provider. This occurs through case record reviews. The LME-MCOs submit their findings from case record reviews to the state on an annual basis.

The LME-MCOs also measure provider performance through the Gold Star Monitoring process. This is a mechanism to monitor provider agencies and licensed independent practitioners.

Agencies are monitored in the following areas:

  • Implementation and compliance with the core rules for the delivery of MH/IDD/SAS.
  • Protection of the individual's rights.
  • Safeguarding the health, safety and well-being of individuals receiving services.
  • Staff qualifications.
  • Compliance with documentation requirements.
  • Medication management.
  • Cultural competency.
  • Requests to add a new service.
  • Non-contract providers.
  • Integrity of billing through post-payment reviews.

Licensed independent practitioners are monitored via the following:

  • An on-site review to evaluate the practice site in terms of accessibility, recordkeeping, the presence of safeguards to assure confidentiality and compliance with HIPAA privacy and security regulations.
  • Record reviews to assess the extent to which technical assistance is needed to ensure state standards for documentation are met and that the documentation is adequate to support billing.
  • Post-payment reviews to evaluate the integrity of billing.
  • A review of practitioner's implementation of a cultural competency plan.
  1. State Audits of MLTSS Program
DMA and DMH/DD/SAS conduct joint Annual Monitoring Reviews on-site at LME-MCOs. The Monitoring Reviews include but may not be limited to a review of:
  • LME-MCO's compliance with the requirements of this contract.
  • LME-MCO's compliance with state and federal Medicaid requirements.
  • LME-MCO's compliance with N.C.G.S. 122C-112.1.

To the extent possible, the review does not duplicate areas assessed by the National Accrediting Body (once LME-MCO accreditation has been achieved).

Thus far, Monitoring Reviews have been led by an external consulting group to ensure that LME-MCOs are having sufficient resources in place to provide managed care services.

  1. Performance Measures and Quality-Related Reports
North Carolina collects a number of HEDIS and HEDIS-like performance measures include the following:
  • Follow-up after hospitalization for mental illness.
  • Readmission Rates for MH.
  • Readmission Rates for SA.
  • Ambulatory follow-up within 7 calendar days of discharge for SA therapy.
  • Ambulatory follow-up within 7 calendar days of discharge for MH.
  • Initiation and engagement of alcohol and other drug dependence treatment.
  • MH Utilization--Inpatient discharges and average length of stay.
  • MH Utilization--Percentage of members receiving inpatient, day/night care, ambulatory and other support services.
  • Chemical Dependence Utilization--Inpatient discharges and average length of stay.
  • Chemical Dependency Utilization--Percentage of members of receiving inpatient, day/night care, ambulatory and other support services.
  • Integrated care.
  • Identification of alcohol and other drug services.
  • Call answer timeliness.
  • Call abandonment.
  • Payment (authorization) denial.
  • Out of network service.
  • Network capability.
  • Unduplicated count of Medicaid members.
  • Race/ethnicity diversity of membership.

North Carolina has also developed several performance measures that are a requirement of the assurances and sub assurances associated with the Medicaid 1915(c) program. Performance measures for a (c) waiver participant include measures addressing:

  • Health and safety;
  • Choice;
  • Quality of the SP;
  • Provider remediation, compliance, standards, enrollment and capacity;
  • LOC process and instrument;
  • Slot transfer and tracking.

LME-MCOS must also provide quarterly reports on:

  • Grievances and complaints;
  • CIs.
  1. LTSS-Focused PIPs
Because the population in the program is, by definition, the LTSS population, all PIPs focus on the LTSS population.

The state requires the LME-MCOs to implement a total of 3 PIPs over the 2 years of the contract. During the first year, the LME-MCO is to implement 2 PIPS, 1 clinical and 1 non-clinical.

Contractually determined appropriate topics for PIPs include:

  • Primary, secondary and/or tertiary prevention of acute mental illness conditions.
  • Primary, secondary and/or tertiary prevention of chronic mental illness conditions.
  • Care of acute mental illness conditions.
  • Recovery/outcome measures.
  • Care of chronic mental illness conditions.
  • High-volume services.
  • High risk services.
  • Continuity and coordination of care.
  • Availability, accessibility, and cultural competency of services.
  • Quality of provider/patient encounters.
  • Appeals and grievances.
  1. Care Coordination
All members are assigned a care coordinator upon enrollment. The LOC assessment is conducted by the network provider and is submitted to the LME-MCO UM team. An ISP is developed by the provider and the provider reassesses the SP annually. Both the ISP and LOC are standardized.
  1. 24-Hour Back-Up
There is currently no requirement for a 24-hour back-up system.
  1. CI Reporting and Investigation
The LME-MCO must submit CI reports as part of ongoing statistical reporting.
  1. Mortality Review
The LME-MCOs convene mortality reviews; however, they are not required to submit their findings to North Carolina DMA.
  1. EQRO Responsibilities
North Carolina DMA contracts with an EQRO to conduct an annual independent EQR. The EQRO conducts 3 mandatory activities:
  • Determining LME-MCO compliance with federal Medicaid managed care regulations.
  • Validation of PMs produced by the LME-MCO.
  • Validation of PIPs undertaken by the PIHP.

In addition, based on the availability of encounter data, the EQRO conducts encounter data validation.

North Carolina DMA recently released a RFP for EQRO services expanding the role of the EQRO to include conducting a statewide consumer experience/satisfaction survey and validation of LTSS performance measures. Previously, only (b) waiver measures were validated by the EQRO.

  1. Ombudsman/ Function
North Carolina presently does not have an ombudsman for MLTSS services for individuals with IDD. There is, however, a state level grievance and appeals center that is housed in the operating agency (DMH/DD/SAS). Data on grievances and appeals from the operating agency are shared in an annual report.
  1. Experience of Care/ Satisfaction Surveys
Each plan (LME-MCO) is currently required to contract with an external vendor to conduct an annual satisfaction survey using an instrument approved by the state.

Additionally, the state supports the collection of Core Indicators surveys for the IDD population.

  1. Membership Oversight
Membership oversight is provided through state level stakeholder oversight provided by the DWAC. This is an advisory body to DHHS that provides input and consultation over implementation and operational phases of the 1915(b)/(c) Medicaid waivers and the ongoing LME-MCO operations (Medicaid managed care, Innovations and LME operations).

DWAC membership includes the following:

  • 3 providers--2 local and 1 statewide.
  • 2 enrollees from state and local consumer advisory committees.
  • 3 enrollees who are not on the state or local consumer advisory committee, 1 from each disability group.
  • 1 member from the External Advisory Committee.
  • 2 members representing the county commissioners.
  • 2 members representing the LME-MCOs.
  • DMA director and chief commercial officer.
  • DMH/DD/SAS director and medical officer.
  • DHHS deputy director for health services.
  1. State Technical Assistance to MCOs
Annual Monitoring and routine interactions with the state determine the need for technical assistance.
  1. MCO Report Cards on LTSS
There are currently no MCO report cards.
  1. Financial Incentives, Penalties and Withholds
There are currently no financial incentives or penalties. The program had instituted both financial incentives and penalties initially with the pilot 5 county program; however, these were removed when the program was mandated to expand statewide.
  1. Other Quality Management/ Improvement Activities
None specified.
CI = critical incident
CMS = Centers for Medicare and Medicaid Services
DD = developmental disability/developmentally disabled
DHHS = North Carolina Department of Health and Human Services
DMA = North Carolina Division of Medical Assistance

DMH/DD/SAS = North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services
DWAC = Department Waiver Advisory Committee
EQRO = external quality review organization
FTE = full-time equivalent
HEDIS = Health Effectiveness Data and Information Set

HIPAA = Health Insurance Portability and Accountability Act
IDD = intellectual and developmental disabilities
IMT = Intra-departmental Monitoring Team
ISP = Individualized Service Plan
IT = information technology

LME = local management entity
LOC = level of care
LTSS = long-term services and supports
MCO = managed care organization
MH = mental health

MLTSS = managed long-term services and supports
MMIS = Medicaid Management Information System
PIHP = Pre-paid Inpatient Health Plan
PIP = performance improvement project
QA = quality assurance

QM = quality management
RFP = request for proposal
SA = substance abuse
SAS = substance abuse services
SP = service plan

UM = utilization management

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