Week of March 7 Budget Update

HHS Appropriations
Medicaid and Piedmont Behavioral Health
On Tuesday, Craigan Gray and Steve Owen finished up a presentation on Medicaid and Pam Shipman from PBH presented.  The Medicaid handout is online here.  The PBH presentation is online here.  The PBH presentation was not much different from other presentations they have done.  Some points that were made that I would like to note:

• The slide that states that the PBH model has management of all public resources, including Medicaid funds, state/federal funding and state institution funds, is misleading.  PBH only covers behavioral health.  Other Medicaid services (primary care, etc.) are covered under the Southern Piedmont Community Care Plan (the local CCNC affiliate).
• State funds account for 20% of the PBH budget.
• Although the slides related to comparative costs for certain types of services are not clear as to scale, they demonstrate no significant cost differential for ICF-MR, 1915(c) services (Innovations and CAP-MR/DD), and possibly outpatient and inpatient psychiatric care (without further explanation of their numbers it is impossible to know if the difference is statistically significant).

Division of Mental Health and the Division of State Operated Healthcare Facilities
On Wednesday, legislative staff  (NOT DHHS staff as was done for Medicaid) presented reduction options related to the Division of Mental Health and the Division of State Operated Healthcare Facilities.  Of particular note:

• It was stated that the cost of ICF-MRs is mostly medicaid, with only a small amount in the DMH and DMA budgets for state dollars, so there wouldn't be much savings to close the DD Centers.
• Total funds spent through the LMEs - $533 mil (state and federal) - $350 mil to community services ($350 mil) and $115 mil in administrative funding (22% of the money allocated to LMEs, $65 mil state and $50 mil federal).  Staff discussed the high percentage of administrative costs (according to the Mercer report the national average is 10-15%) and laid out options to consolidate and reduce the number of LMEs.  For community services funds, staff suggested standardizing the service package of benefits among LMEs, creating a standard benefits package among LMEs, and instituting a co-payment as reduction options.  There were alse questions about the LME fund balances.
• Staff put forth closing the Wrights School as an option.
• ADATCs – there is not really an option for this, but could see if there is a private market.
• Advocacy staff - $3.5 mil in salaries/fringe (both state and federal cost) – 40 positions to serve 15 facilities, 23 throughout communities.  In his response, Secretary Cansler pointed out that the advocacy staff is crucial to the facilities, and the amount saved in state dollars would be minimal.
• CRH Hospital Administrator Contract – could save $30K by hiring as an employee.  Cansler also responded to this point in his response.

Education Appropriation
K-12 Education Reduction Options - handout here.  Some options discussed include:

• Eliminating $9 mil in support for Child and Family Support Teams
• Children with Disabilities Reductions: 2 reductions are discussed: 1)  3.4, 4.2 and 5% reductions to the state allocation for children with disabilities ($23,964,707, $29,042,061, and $34,694707 reductions to $693,894,148).  Staff is further investigating this option regarding federal Maintenance of Effort requirements for IDEA funding.  These options were not in the Governor's budget.  2) The Governor's budget included a $7 mil reduction in anticipation of a reduced headcount.
• Reduce funding for the Residential Schools for the Deaf and Blind by 5 and 10% ($1.6 mil and $3.3 mil out of $32.6 mil budget).
• There are also proposals to reduce funding for teacher assistants, local school district central office administration, principal and assistant principals, instructional support (guidance counselors, social workers, etc.), eliminate funding for staff development, retirement incentives for LEAs and to eliminate the More at Four/DPI Office of School Readiness.

Corporal Punishment Bill Protecting Kids with Disabilities Passes the NC House

HB 1682, Corporal Punishment for Children with Disabilities, which will allow parents of children with disabilities to opt out of corporal punishment and mandate tracking of data, was approved unanimously by the House yesterday! The bill will now go to the Senate.

And We're Off

The North Carolina General Assembly is back for the 2010 short session. I am going to try and communicate the happenings here on the blog as often as I can, but at least once a week. In just a few short days this week (the legislature convened on Wednesday, May 12), lots has been going on. See the DRNC legislative agenda on our website if you have not done so already.

Bills Filed Relevant to People with Disabilities and the Work of DRNC

• HB 1682/SB 1138: An Act to Prohibit the Use of Corporal Punishment for Students with Disabilities as Recommended by the Joint Legislative Education Oversight Committee. This bill seeks to amend the law to say that Corporal Punishment shall not be administered on students with disabilities. (DRNC Agenda bill).
• HB 1683/SB 1140: An Act to Delay the Sunset of an Act Pertaining to the Discipline and Homebound Instruction of Students with Disabilities as Recommended by the Joint Legislative Education Oversight Committee. This bill moves the sunset on this provision from March 1, 2011 to June 1, 2013. The provision was added to the statute on discipline and homebound instruction by 2008 legislation providing that a local educational agency shall be deemed to have a 'basis of knowledge' that a child is a child with a disability if, prior to the behavior that precipitated the disciplinary action, the behvior and performance of the child clearly and convincingly establishes the need for special education. NCGS 115C-107.7. (DRNC Agenda bill).
• HB 1674/ SB 1134: A Joint Resolution Authorizing the 2009 General Assembly to Consider a Bill to be Entitled an Act to Protect the Freedom to Choose Health Care and Health Insurance. This would allow the legislature to consider a bill with that title, presumably to direct the state away from provisions of the federal healthcare reform laws. There was also a bill filed seeking to amend the NC Constitution relating to health care services.
• HB 1698: An Act to Update and Clarify NC's General Statutes on Older Adults and Long-Term Services and Supports, as Recommended by the NC Study Commission on Aging. This bill would update language concerning older adults in the long-term care statutes.
• HB 1703: An Act to Direct the Division of Aging and Adult Services, Department of Health and Human Services, to Study the Issue of Criminal History Record Checks for Current and Prospective Owners, Operators and Volunteers of Adult Day Care Programs and Adult Day Health Services Programs, as recommended by the NC Study Commission on Aging.
• HB 1730: An Act to Authorize the NC Health Insurance Risk Pool to Contract with the US DHHS to Administer the Newly Created Federal High Risk Health Insurance Pool. This bill will allow the the NC Health Insurance Risk Pool, a nonprofit entity supported by state funds, to enter into contracts with the US DHHS to administer the federal high risk health insurance pool established under Health Care Reform.
• HB 1732: An Act to Direct DHSR, DHHS to Coordinate a Review of the Education and Training Requirements for Nurse Aides, as Recommended by the NC Study Commission on Aging.
• SB 1150: An Act to Appropriate Funds for the NC Special Olympics. This bill would appropriate $100,000 for the 2010-11 fiscal year.

Senate Budget Recommendations

Several Senate Appropriation sub-committees met on Friday to present budget recomendations. The Education sub-committee did not meet. The Health and Human Services (HHS) sub-committee met, and will meet again on Monday at 4. Highlights of differences from the Governor's budget are below:

Justice and Public Safety (JPS)

• Funding for the Samarkand Youth Development Facility was eliminated (The Governor's budget restored funding for Samarkand).
• Funding for wilderness camps was restored.

Health and Human Services (HHS)

The proposed Senate budget takes less reductions overall than the Governor's budget.

• It eliminates an additional 20 positions within the Division of Central Management.
• Eliminates 27 positions from the Division of Public Health.
• Eliminates state funding for vaccines (the Governor reduced funding).
• Reduced the appropriation to NC Health Choice for expanded enrollment.
• Eliminates 50 positions within the Office of Education Services (there are currently 79 vacant positions, and 20 of them are educator/aide positions), and an additional 12 administrative positions (which are specifically identified). However, the Senate's budget does not include the reduction of residential services to 4 nights. It also does not include the suspension of on-site summer programs.
• The Senate budget includes an expansion item in the budget for the Divisions of Services for the Blind and Services for the Deaf and Hard of Hearing: $75,000 for contracted electronic information services, which allow visually-impaired persons to access print media through telephone systems.

The Division of Medical Assistance (DMA) budget has several changes:

• Keeps the $41 million reduction in enhanced mental health services, which includes delaying implementation of peer support services until January 1, 2011, but also specifies changes to Community Support Team (CST) to include reducing the limit of hours per week from 18 to 5, and reducing the rate from $15.60 to $11.80 per unit.
• It does not include the reduction in the Governor's budget for durable medical equipment program improvements.
• It does not include the provision in the Governor's budget related to the addition of an indepenedent asesssment on high-cost services.
• It does not include the proposed changes to several optional services: podiatry services, speech therapy, physical therapy, occupational therapy and respiratory therapy, adult dental care and private duty nursing.
• It does still include the proposals related to Personal Care services: eliminating the program in the community, but applying for a 1915(c) Home and Community Based Services waiver for personal care services in Adult Care Homes.

The sub-committees and the full appropriations committee will be meeting early next week to vote on the budget, which will then proceed to the Senate floor.

Governor's Budget Recommendations April 20, 2010

Governor Perdue released her recommended adjustments to the state budget today. The full document is available online. The budget cuts approximately $1 billion from the overall state budget. Just a reminder, this is just the beginning of the budget process - the budget has to go through the Senate and the House, and back to the Governor before all is said and done.



Of particular note for people with disabilities:

• In the Division of Medical Assistance recommendations, there are several proposed changes to the Medicaid program that are predicted to save money by reducing or eliminating services:

Implement independent assessments on high-cost services to ensure proper utilization. Targeted rate reductions and "other measures" may be implemented to achieve necessary savings.

Various changes to optional services to improve utilization management, including reducing the maximum number of visits for adult speech therapy, physical therapy, occupational therapy and respiratory therapy.

Elimination of in-home Personal Care Services for adults and the creation of a new program for adults with the most intense needs.

Changes to private duty nursing (PDN) services, including transitioning adult PDN recipients to a new Community Alternatives Program (CAP) technology waiver. PDN services will continue to be available for children but it is recommended that independent assessments be conducted for children that receive the service.

Changes to mental health services, including modifying Community Support Team services and delaying the implementation of Peer Support from July 1, 2010 to January 1, 2011.

Limit adult dental coverage to emergency care only.

Reduce the number of outpatient mental health service visits for children before approval from 26 to 16.

• There are proposed expansions in the Division of Medical Assistance budget: One regarding adult care homes: "Funds are recommended to develop and implement a 1915(c) Medicaid Assisted Living waiver for individuals that reside in adult care homes that meet skilled nursing level of care and currently receive State County Special Assistance (SCSA). The waiver will allow fora targeted reimbursement based on acuity levels for the personal care services provided in adult care homes." ($9 million appropriation)
• There is also a proposal to allocate $8.5 million to expand NC Health Choice enrollment.
• In the Division of Mental Health, there is estimated savings from the conversion of the Whitaker School to a PRTF ($1.9 million). There are also proposals to provide funding to develop local in-patient bed capacity ($12 million for an additional 50 beds), improve the quality of care in residential facilities through training of staff ($534,795), and to restore $40 million to state funded mh/dd/sa services.
• In the Division of Health Service Regulation, there are several proposals to replace state appropriations with federal receipts (from civil monetary penalties assessed against nursing homes and Medicaid receipts to support licensure and certification activities), to establish fees (for adult care home medication aide and administrator testing), and to make the jails and sections receipt supported ($420/facility and $17.50/bed).
• In the Division of Vocational Rehabilitation, there is a proposal to reduce the Basic Support Case Services program by $2 million on a non-recurring basis; and to reduce the Independent Living program budget and staff by $1.3 million (eliminates 8 recreational therapist positions).
• In the Division of Social Service recommendations, the Governor is proposing a change in the percentage the state pays for Adult Care Home Specialists who monitor and inspect adult care homes. Federal funds pay for 50% - currently the other 50% is split with 40% paid by the state and 10% by the counties; this proposes that the state pay 25% and the counties 25%. An elimination of funding for the school-based Child and Family Teams pilot ($420,804) is also proposed (supported 12 team facilitators) - also eliminated from the Division of Mental Health budget.


• In the Division of Public Health budget recommendations, an additional $3 million is recommended for the AIDS Drug Assistance Program to allow eligible individuals on the waiting list to be enrolled.


• In the Office of Education Services in DHHS, it is proposed to suspend on-site summer school programs ($280,000) and to permanently reduce residential services from 5 to 4 nights at the residential schools ($619,558).


• A $100,000 appropriation to the Special Olympics is proposed.


• In the public schools, state funding to local education agencies (LEAs) is being reduced by $135 million and the amount appropriated for central office administration in LEAs is being reduced by 5%, $5.4 million.


• Funding for Child and Family Support Teams through public education is being reduced by $2.5 million. $9.1 million will remain to support the initiative.


• In the community colleges, $19.8 million will be restored to fund prisoner re-entry education (limited to basic skills and continuing education courses that ensure adequate literacy and job skills to pursue a productive life but curriculum courses and instruction at federal and local facilities will not be offered).


• There is money being allocated on a non-recurring basis to the State Board of Elections to provide matching funds for the Help America Vote Act (HAVA) grant application. This will allow for the maintenance and licensing of voting equipment.
• In the Department of Justice budget, there is a proposal to eliminate the NC Legal Education Assistance Fund program (NC LEAF), which provides loan repayment assistance to legal services attorneys as well as public defenders and district attorneys.
• In the Department of Juvenile Justice and Delinquency Prevention, there is one expansion item: to restore funding for the Samarkand Youth Development Center. It is recommended that the Woodson Wilderness Camp and the Macon County Multi-Purpose Home be eliminated, that the Eckerd Wilderness Camp program be reduced by 155 beds, and that the direct appropriation to the Juvenile Assessment Center be eliminated.
• In the Department of Corrections budget proposals, the Governor has proposed the establishment of operating reserves for the Central Prison Hospital and Mental Health Facility and the NC Correctional Institute for Women Mental Health Facility (both are scheduled for completion in August 2011).

Stay tuned for updates and more details as we move forward!

Proposed Rule on Telepractice for Speech and Language Pathology and Audiology Services

A proposed rule regarding "telepractice" for Speech and Language Pathology and Audiology Services was published in the March 1, 2010 North Carolina Register. The new rule defines telepractice as "the use of telecommunications and information technologies for the exchange of encrypted patient data, obtained through real-time interaction, from one site to another for the provision of speech and language pathology and audiology services to patients through hardwire or internet connection." Written comments or objections must be submitted by April 30, 2010, and a public hearing will be held April 23, 2010 at 1:30 pm at the Sheraton Imperial Hotel in Durham.

Implementation Update #70 was posted March 2

I am running a little behind, but just in case anyone missed it, Implementation Update #70 has been posted to the Division's web site and can be found here: http://www.ncdhhs.gov/mhddsas/servicedefinitions/servdefupdates/index.htm. There is information on:
• Suspension of Mandatory Cost Reporting For Rate Adjustments
• CABHA Update (The Centers for Medicare and Medicaid Services (CMS) have approved a State Plan Amendment (SPA) that will allow only Critical Access Behavioral Health Agencies (CABHA) to provide Intensive In-Home Services (IIH), Community Support Team (CST), and Child and Adolescent Day Treatment services effective July 1, 2010. There is also information about the continuum of care that will be expected from CABHAs and medical director exceptions.)
• Impact of Merger & Acquisitions on Enrollment/Accreditation/endorsement
• PSR Service Notes
• Child and Adolescent Day Treatment Endorsement Checksheet and Instructions
• MOA for Child & Adolescent Day Treatment
• New CAP/Targeted Case Management form for MR/DD Submissions to VO
• Policy Changes for Case Management (Limit of 3 hours per month for CAP/DA, CAP/Choice, CAP/C, CAP/MR-DD, Targeted Case Management for Persons with Developmental Disabilities, and Early Intervention. Six additional hours (24 units) may be available if needed for completing an assessment, completing a reauthorization or continued need review, or for a crisis/emergency situation. EPSDT may also necessitate additional hours. There is additional information about recipient due process.)
• Extension for Provisionally Licensed Billing
• DMA Program Integrity contract with PCG
• Payment Error Rate Measurement in NC
• Medicaid Provider Payment Suspension
• Census 2010