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House | May 28, 2013 | Committee Room | Health Part 1

Full MP3 Audio File

We'll call this meeting to order. Pages serving the committee this morning are Cindy Beaver, Emily Hishram, and Madison Hendrick. Thank you for your service to the committee this morning. Sergeant at Arms serving the committee this morning are Fred Hines, Reggie Sills, John Brandon, and Mike Clampett. Thank you gentlemen. We have one bill before the committee this morning, Senate Bill 208, Effective Operation of the 1915-BC Waver. There is a PCS before the committee without objection. Representative Dollar to present the bill. [SPEAKER CHANGES]Thank you, Mr. Chairman, members of the committee. What we have here, Senator Tucker sent over to us in Senate Bill 205, a framework which what we have done through as number of iterations, and I want to thank the staff, Jan Paul, Walker Regan, Dr. Porter, Sara Riser, and I think some others that have worked on this is to refine the bill Senator Tucker sent to us. I think it was termed at one point in time the 'Red Flag Bill', and those that are familiar with that, we certainly kept to the spirit and refined it further. Let me just try to explain, and I'll try to keep it relatively brief and obviously we'll be available to answer any questions you might have. This is actually the 3rd, or at least in my view, it's the 3rd in a series of bills. General Assembly made a decision in 2011 to expand what's call the 1915B, and 1915C waivers statewide. Under those waivers, we operate in Medicaid or mental health services, and our intellectually or developmentally disabled services as well substance abuse services. The state had established the pilot some 7, 8 years ago with Piedmont Developmental Health. That pilot demonstrated both tremendous strength in terms of the provision of quality services as well as considerable savings with regards to state funds. It was actually a nationally recognized model. So the decision of the General Assembly in 2011 was to expand that state wide. Now, since that time, since the passage of House Bill 916, the House also passed last year House Bill 191, if I remember correctly, it was a bill that with further refining, addressing some managerial issues, some governance issues. There was a committee put together of stake holders. That bill was crafted, it was passed in furtherance of making the transition from the local management entities into the public managed care organizations. The target date was set, and will be met, and is being met July 1 of this year, for the entire state to be operating under the 1915 B and C waivers. We knew it would not be an easy transition, and it has had its challenges. The key, I think, in mental health is for us to have a plan and stick to it. I think that's been the thing that has troubled the state over the years. We don't always stick to a plan that we make. This time we're trying to stick to it, and we're also trying to make adjustments as we need to make those along the way. Senate Bill 208, in my view, is sort of the 3rd bill in this series. Some of the issues that have come up, there were questions with regard to the secretary's authority to transition to a small number of LME-NCOs. As many of you know, there were 40 some groups, several years ago

was winowed down to 23 in the initial movement to the 1915 DNC waivers, we transitioned again down to 11 and are in the process of moving to 10 as Western Highlands is becoming a part of Smokey and what is going on there and what was felt as there needed to be clarification for the Secretary as other issues have come up and come to the ?? there needs to be clarity as to what the Secretary's specific authorities are, how those operate and what are those parameters and that is what you see in front of you in Senate Bill 208. Section 1 is an additional clarifying power. Section 2, the title says the actions by the Secretary to ensure effective management of behavioral health services, under the waiver, these are the things to be looked at. If you turn over to page 2 the bulk of page 2 in items 1, 2 and 3, are the areas, if any one of these is not being met, the Secretary is directed to take action to combine that essentially failing LEMCO?? in with an LEMCO?? that is operational and has the capacity. Item 1, there on page 2, basically involves financial solvency, item #2 is the payment of claims and Item #3 is the appropriate documentation that you have to have to operate. Further on there are specifics in here with regard to time tables and how the non-compliant LEMNCO?? is to move forward. If you look at page 3, down on line 14, under item D, you see 7 separate sections in there. These are areas that if the LMNCO?? is found to be deficient in one or more of these areas, there has to be a clear plan of correction put into place where we have deadlines and certain ?? to move forward and to get these items and these areas corrected. Moving on down, beginning at the bottom of page 3 and moving on over to page 4, we have provisions in this bill that lay out how the transitional, when LMNCO?? is being susumed by another, how that area and that MCO?? is to be susumed, how we ensure successful transition to the larger group and issues like for example, ensuring that providers are going to be paid for and that the new larger area is going to be representative of the area that is being taken over. Risk reserve, there is a lot of technicality and so there was a tremendous amount of work put into working through these issues making sure we have a process that will operate efficiently and effectively and will both serve as a protection for clients receiving services as well as protections for providers in the process to ensure that during the transition they will be paid and we will have a smooth transition. Obviously, right now there is a transition going on between Smokey and Western Highlands and from what I understand that they are working on, their transition will be able to fit within what we are looking at here in this legislation. There are, down under section 6 on page 5 and moving forward, there are some clarifying technical language, there is under, on the last page, you will see, that under item #8, we have establishment of a county commissioner

Advisory board as these LMEMCO's get larger our counties have expressed an interest to continue to be engaged. They're engaged anyway because they're appointing the members of the LMEMCO governors board, but we've also provided for an opportunity to have an additional advisory board of county commissioners that can be established to sort of relieve the concern about continuing to have input form the counties. We are also in this process eliminating under section nine the ability to have a single county LMEMCO everybody is going to have to operate in the state under the same set of rules and regulations so we're taking care of an issue that was there. Mr. Chairman, I covered a lot of ground, we certainly will attempt to answer any questions or probbaly call on staff if folks have questions that they want to ask. I would just quickly sum up to say what we are committed too and what I hope this committee will endorse and what this general assembly will endorse is a continued commitment to have an effective wayward [??] program statewide in the area of mental health. Mental health is a difficult area in need of reform. I believe that we have established the structure to have one of the best mental health systems in the country. But we have to continue to work at it to make sure that it's operational and to make sure that our goal of having statewide effective operation of the 1915 B and C waivers is the reality moving forward. Mr. Chairman I'd be pleased to answer any questions. [SPEAKER CHANGES] Representative Blackwell. [SPEAKER CHANGES] Thank you Mr. Chairman. A couple of concerns if I may. Legislature in 2001 as I recall did mental health reform and then about 2007 it seemed like everybody was surprised and concluded, well my goodness, it's not working. And it was almost although we spent six or seven years walking away from a reform that had been put in place that was supposed to ensure patient care and communities outside the traditional psychiatric hospitals, and it wasn't happening. My question is as we move to these new LMEMCO's, is there something in this bill or in the plan for the operation that is going to provide that continuing monitoring process of patient care and to guard against complaints that I hear often at home of concerns that MCO's and LME are going to satisfy the state financially by keeping down cost, by denying needed services. So what's the plan for monitoring how well this is working so we don't get surprised down the road that it isn't and how are we could to be sure that the care is happening rather than just the financial management? [SPEAKER CHANGES] Well I would answer that in a couple of ways. One of the things that we did last year in house bill 191 was to change the governance model. That will not be fully in effect until October 1 of this year. So and in this governance what we did was we ensured that on the LMEMCO board that we would have additional, financial and legal expertise so that folks could successfully operate what is essentially a small insurance, well not a small but an insurance company, a significant insurance company. In addition to that we balance that by bringing back what had been lost over the years and that was representation on those boards of consumers and of the CEFAC [SP], the advocacy folks, in the various areas. So folks from substance abuse, mental illness and IDD would all have representation, voting representation on the actual LMEMO boards. And the reason why the element was brought back was to ensurer that the...

As for should be and would be able to do with a responsive and the end of the forces that they're talking about would be heard like there is this the four for making the decisions and, in the process of transitioning from two that that will not really be fully complete until October 1 and two , fell two and that's the department had any level and monarch trying to use local LME stash it relates 25 those services are being provided quality of services to travel from stopping the second item and it's not simple, but that it is set to stand at attention that are not A% no: ole miss those taking a medication that if they take a break and a member function and stay out of the merger cheer and some study of problems with Al bodies is back, the monitored by somebody other than the L.a. five in Seattle law to determine that the alleys and CIA does not itself, (SPEAKER CHANGES) with two hits and five shortcomings notwithstanding the ability of some of the members questioned you have the short answer is yes vote four, alone or 998 era when sheriff's chairman wishes to recognize kill across the from the department of health and human services talk about how they are monitoring the LME and she and should be-old mission two is obviously individuals if they , not receiving appropriate services and they may have an image various administrative appeal process internally and then ultimately would with only a distressing telecast of the sabbatical assistants M to some axiom Elliott question about managing your station 70 distance from their solid CM because they can your concern that that the ancestral BMC within their budgets that cutting services we do about it said M got this increases on a monthly basis and authorizations that to my ulcer the action and ESS 89 and a monthly basis Evelyn; the set-UPS and amateurs haven't turned A.H. ms at Minot said M I annual access to the crowd NCS FCC master plan C and CSDA Campanula says Linda lee (SPEAKER CHANGES) Iacocca said assistance for the panic and services provided to their Kashmiri at ms attacks, slashed by beginning in October we must act like inside plans to accompany any claim that stand CMP separate minors seeking Montreal station just like we did an old system can actually know how many staff people are said by service , extending how much are those services are costing by the NCS attacks leach & S ms-ms and officials next month to some 800 in 50 what happened to this 150 individuals we'll sell can't find annual reviews and the mariner this amigo in Santa Ana, administrative operations, actually teach are reduced to a services staff SDA, a sampling of this CD cracked, but the sessions adding that that have fixed by the NCS and nine BS SS C something called = monitoring MSN selection process the SEC convention that allowed too many active another level by the providers by joining the ranks of the clients are they making sure that people are taking their medication that the AC treatment, and that's the FDA and eventual outcome by the ANC is really too much said about an hour to make sure that providing the best quality of service says(SPEAKER CHANGES) Ann finaly and to have consumer satisfaction surveys, DDS as the consumers like Adele wang M the services they receive when I receive an ms attacks and the measures idealization from the NCS says things like the illustration and customer relations Internet economy and our basest is to ensure that 659 ms L.a. levels of caring in Sunland happening at hospitals and actually a lot of different names, monitored -service intensive care until it S and the speaker questions this level that quick uneconomic why somebody else a chance to buy ??............

It seems to me that, as we, or I understand, are moving towards more electronic medical record, and the filling of prescriptions, that especially with people we have a concern whether they're being compliant in taking their medications as they should, that if somebody is electronically filing for reimbursement for a medication, and if we've got a medical record for someone who's on Medicaid saying they're supposed to be getting it every 30 days, it ought to be sort of a technological assignment, that doesn't sound to me like it ought to be tough to say, I Joe Blow is being compliant in taking his medicine, and if he isn't is somebody following up with him. [SPEAKER CHANGES]Mrs. Crosby. [SPEAKER CHANGES]Kelly Crosby, Division of Medical Assistance. I agree with you, and I wouldn't say that through CC-NC, who's our medical home for most of the individuals with serious medical illness who are on these type of medications. One of the things that CC-NC does do for Medicaid recipients is look at their medications, try to justify medications against each other, look at who's refilling these prescriptions. CC-NC is doing a lot of this in partnership with the LME-MCOs, they do have access to all those medications through their database so they're able to see some of our higher end individuals with mental illness to make sure that they're refilling their prescriptions, that different prescriptions aren't counteracting with each other, and I know of at least 1, maybe more of our MCOs have actually hired specialty pharmacists to actually look at this. So, we do use a lot of our pharmacy data to make these types of decisions. It's really more at the, people can fill their prescriptions, and you can monitor that, but really it is the individual provider that has a relationship with the person, that knows that they're actually taking those medications or not. So, that's what I was referring to for about the MCOs having to monitor their provider network to ensure that those clinical interventions are happening. [SPEAKER CHANGES]Representative Fulghum. [SPEAKER CHANGES]Thank you Mr. Chairman. The question for the sponsor in regards to the contemplated further NCO development for the rest of the Medicaid delivery. Are they going to overlap these MCOs as we see them now for behavioral health care to cut out confusion, or perhaps keep them add to the confusion? Is there going to be an Eastern, Central, and Western MCO contemplated at least in the HSS proposals that we've heard floating around that will actually be proposed for these same regions? [SPEAKER CHANGES]I think ultimately, well, the General Assembly will make the decision on what kind of Medicaid system that we have in the state. What we launched into here in 2011, was an expansion of an incredibly successful pilot that started out in 5 counties, that's expanded now, PBH has become Cardinal Innovations. You know, none of these things are easy, and what we're doing in this Senate Bill is a further refinement of that process. So I think the General Assembly is, in my impression, is very committed to having a successfully operating state-wide 1915B and C waivers for our mental health, substance abuse, and intellectually and developmentally disabled services. And I would expect that we want to continue to keep that strong and moving forward down the road. That's certainly the intent of this legislation in which we're further clarifying. We're ensuring that the LME-MCOs are going to be strong. If they have to merge, how they merge, how they operate, what the standards are, and obviously ensuring that our partner, our very critical provider partners all across the state, you know, will be paid, particularly if there's a transition to fewer LME-MCOs. [SPEAKER CHANGES]Representative Farmer-Butterfield. [SPEAKER CHANGES]Thank you, Mr. Chair, I had a couple of questions. The first one was in reference to the fund balances in section 5B on page 5. And my question basically is, I think the change, if I'm correct, is due to

Of the phase of where we are, with the MCO’s transitioning emergement to managed care. How has that worked, the existing situation in terms of prorating funding for the transfers? Has that worked well with the MCO’s when they merged? [SPEAKER CHANGES] Well what we’re, and staff may be better to answer the question but, what we have had prior to has been LME transitioning into MCO’s for which we had procedures and then contracts and the like to do that with. This is dealing more with the merging of an existing LME MCO in with another LME MCO and trying to be clear about how that process works. And to ensure that providers are going to get paid. That people are going to be served. That areas that are being subsumed under a larger area are going to have representation on the board. Making sure that the appropriate risk reserve is going to be able to be maintained in that process. And I don’t know if Ms. Paul would want to comment further. [SPEAKER CHANGES] If I may, Thank you Mr. Chair. Representative Farmer-Butterfield, with regard to how that has worked in the past, research staff would need to defer to either financial staff from the department or fiscal research staff who is present. With regard to how that has actually from a practical standpoint operated on the ground in the past. I don’t know if Ms. Bush is present, or if fiscal research has anything to add. [SPEAKER CHANGES] Well what we haven’t had is we are just now having our first MCO merging with another MCO. Which is the merger that is in process with Western Highlands and Smokey Mountain. And it’s my understanding they’re close to a contact agreement for how that is merging together. And in certain respects that’s going to be the test case, so to speak, for how to make that functionally happen in an appropriate way and they seem to be moving forward well considering the circumstances. [SPEAKER CHANGES] I’ll get with fiscal staff on specifics in terms of how it’s worked with others that have merged. Other question that I had [SPEAKER CHANGES] Follow up [SPEAKER CHANGES] Yes, follow up final one. Who provides compensation and assistance to the MCO’s when they merge and they go into the waiver? Those that are unfamiliar with it, who helps them move forward in the system to make it work? I know we got, what, PBH, which is now what, Carnival, are they doing any consultative assistance with these other… [SPEAKER CHANGES] Well they have done other- Oh, I’m sorry. The ocean. OK? Well they have. They’ve done a tremendous amount over the last couple of years in trying to provide assistance and help and the like. But obviously the department is the one who has taken the lead in providing that consultation and oversight and assistance. [SPEAKER CHANGES] Reason I ask is because I’ve heard some comments about the need for that. ?? [SPEAKER CHANGES] Representative Avila. [SPEAKER CHANGES] Thank you, Mr. Chairman. I too have a couple of questions. One of the things in presentations as well as in private conversations with managed care companies. One of the things that they tout is an advantage or something that they’re able to do is provide services that aren’t necessarily paid for by Medicaid. In other words, the perfect example we heard repeated several times by our director of Medicaid is the issue of the lady repeatedly going to the emergency room because she didn’t have air conditioning. Do the MCO’s with their budgets, do they fund this or free of that same type of restriction that they have a flexibility to really, if they see a need that isn’t quote on the list, that they can take care of it? [SPEAKER CHANGES] Well they do manage the LME MCO’s also manage state dollars, as well as federal Medicaid dollars. And in terms of working to assist someone with a need that might be outside of the medical need, it’s my understanding that most of them

...work can do that sort of thing. In these communities, people know where resources are that are outside the realm and obviously, they work as they can to help people identify additional resources, whether it's an air-conditioning program or fuel program that's run through some other part of State government, making sure people get hooked up to those resources. [SPEAKER CHANGES] Follow up? [SPEAKER CHANGES] Follow up. [SPEAKER CHANGES] There's language in here about an LME MCO disengaging. What is the process for one of the clients or service people who are receiving services disengaging? I mean by that, if they move in the State from one MCO to another, what is the process? Because we recently heard some issues and I actually had run a bill on the county of origin that was kind of a stumbling block. What has been put in place to make the movement of our citizens from one are of the State, with this new set up, more convenient and no lapse in services and things of that nature? [SPEAKER CHANGES] I think we're hopeful your bill is going to pass the General Assembly because I think it takes care of that. That's not really part and parcel of this legislation. Ms. Crosby, at the direction of the Chair. [SPEAKER CHANGES] Ms. Cosby? [SPEAKER CHANGES] I don't know if Ms. Crosby has comments she wants to make about those individuals. [SPEAKER CHANGES] Hi, Kelly Crosby, Division of Medical Assistance. Right now, at least on the Medicaid side and the State funds follow. There's a contract for a particular catchmen area. That side base of the capitation, that's how they enroll providers, that's how Medicaid eligibles get services, they know their catchmen area. That's the LME that's on your Medicaid card. To actually have one county go to another LME MCO, it's a big deal. A lot of things need to get changed at the system level in terms of resetting the capitation, making sure providers all move to the other MCO, consumers all are able to maintain their services, getting the waiver approved by CMS to move one county to another LME. Were that ever to happen, and I think Smoky Mountain and Western Highlands merging together is a good example of that. What they have done is put together a project plan for us and it's something that we monitor with them on a weekly basis. Because at the State level we've got to do all those things in terms of tell CMS we need to change the waiver application, that these new counties now belong to this MCO. We have to change the capitation rate entirely and get it actuarialy certified with CMS. We have to have a transition plan that says if you were a provider formerly enrolled with Western Highlands, Smoky will be able to just accept you into their provider network. If you're a recipient, how are we going to do outreach and education to all the recipients to know that they can maintain their services. Hopefully, with the very same provider who's now just a Smoky Mountain Center provider. So it really is, there's administrative things we have to do, but there really is an on the ground level project plan that has to happen in terms of educating providers and consumers and making sure that to the consumer at a provider agency people are transitioned into services. That's something that we've required all along throughout this transition that MC has touched every provider and all recipients to ensure that folks are able to transition from one provider to another, or one MCO to another. It's a lot of work and it's quite complicated. [SPEAKER CHANGES] Mr. Chair, clarification please. I was asking, actually, the consumers changing. Say if you lived in Buncombe and you moved to Raleigh to Alliance, what process do they go through when the provider that they've been using in Buncombe and they'll need somebody new. What's the step by step process you use for that person to re-establish services and get payments and things of that taken care of. [SPEAKER CHANGES] Kelly Crosby, Division of Medical Assistance. I'm sorry I answered the wrong question. That's a bit of a messier answer to be perfectly honest with you and I think that is why you've introduced your bill. Individuals are tied by their county to particular LME. They're county in our Medicaid eligibility system determines which LME they're assigned to. We know that that is challenging for children and adults who have a county of eligibility in one LME but may have a residency or a treatment facility several counties away, or many counties away. What actually...

What happens is two things. Sometimes people just move and they go to they have to go to the new county DSS and register their new address and get a new county eligibility. Therefore they get a new EMO on their Medicaid card and the got to engage in services there at that point when the gout through that process and get a new LME the LME is notified they know ever month the new eligible are they have to provide outreach and information about their private network and their services to engage them in new county that is if they have moved. Probably the worst part about that process is that thee county of eligibility can change can take 30 to 60 days and that is something that we are we have a group trying to streamline that for individuals who literally have moved across the state and have to get seat a new county probably the more challenging and we have a work group working at this too are those individuals who have individuals at one area and they are just so we have providers across the state all overt the place who have to enroll with different LMEs some of them only have to reenroll with an LME with one individual who they are serving and its pretty complicated but I do believe we have a dedicated group looking at those law around eligibilities seeing if there is anything we can do about stitching county eligibly quicker but also the besides that while that gets done what can we do for providers who are providing services for single people across multi county lines who do very wink standardized lines so the individual can maintain their same provider they can get paid in a timely fashion and not have to go through a lengthy enrollment or credentialing process while the the other LME. I think ideally what we just really want to have a state uniform state wide credentialing for any provider yes a LME can choose what provider what enrolled in Medicaid if you will the LME can change what provider they want to deal with so providers don’t have to be difficult. No matter where an individual lives they can go they can maintaining their same providers and providers scan get paid. It is not a neat process right now. [Speaker Changes] I have just a couple of questions one has to do that all LMEs of the phrase I used is a bathroom functions that there is something in this bill that would authorize this secretary to standardize back crew functions or did I miss that? I think that has been one of the big problems with the mergers that a lot of LMEs have had their own systems or billing systems and haven’t been able has cost them billing problems [Speaker Changes] Obliviously that has been worked on wet me refer that to Ms. Paul. [Speaker Changes] Mr. chairman if you can recognize the doctor so she can respond [Speaker Changes] Consultant to the general assembly the can you ask the question one more time again [Speaker Changes] It has to do with let me put it this way I believe that the house bill 916 authorizes the department to ensure that the LME that are coping on board with MCOS would adopt the back crew ??? that were held by PHLD that didn’t happen so that has created some problems so I understand there is a process going on that would im fine if PBSH needs to change I don’t think you have to something needs to be negotiate but how is that going to get the back room function change especially if a MCO changes and has to merge if their back room functions are different that at is going t to make the merger more difficult. [Speaker Changes] Actually 3 things toing on in relation to that [Speaker Changes] The first one is internal the ??? community programs has been working with each of the 11 LME and CEO to standardize their back room processes and information technology IT Claims, billing contracts TSO that’s going on within in that group so that they can transmit information one to within each other

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[Speaker changes.] [Speaker changes.] [Speaker changes.] [Speaker changes.]...been done to tweak this model and to make it work better. Appreciate it. [Speaker changes.] Representative Blackwell, for brief comment or question. [Speaker changes.] Quick question. Maybe for staff. Following up on the concern that Representative Insko is discussing about how small we might get. Does the provision that is in this budget that allows for merger, does it limit it to simply over time a reduction in the number of the LME's, MCO's...or does it also allow that a new entity could be created or that an existing one could be divided. In other words, does it work both ways or does it only work to get smaller? [Speaker changes.] I think the anticipation would be that...you're not gonna grow MCO's. You're not gonna see be twelve or thirteen LME/MCO's. That would not be the direction. It could get smaller but it would not get larger and I don't see any of the groups looking to split in terms of where they are. [Speaker changes.] Representative Burr. [Speaker changes.] Thank you, Mister Chairman...just for a motion at the appropriate time. [Speaker changes.] It's the appropriate time. [Speaker changes.] Thank you, Mister Chair. I move that we give the proposed House Committee Substitute to Senate Bill 208 a favorable report; unfavorable as to the original. [Speaker changes.] You've heard the motion. All those in favor say "aye". (Ayes.) Those opposed. The ayes have it. The motion passes and the bill will be reported to the floor. [Speaker changes.] And, Mister Chairman, thank you and the committee and also, Senator Tucker's over here. Thank him for all his hard work on this legislation. [Speaker changes.] Thank you, Senator. [Speaker changes.] This meeting is adjourned.