The NC Department of Health and Human Services has issued a new communication bulletin that should make it easier for people who have the Innovations Waiver to get the services they need. This bulletin is the result of Disability Rights NC’s complaint against the State of North Carolina over the use of budget caps to limit individuals’ access to services.

The bulletin goes to all of the state’s Local Management Entities/Managed Care Organizations (LME/MCOs) and clarifies several important principles concerning the authorization of waiver services.

Important Terms

The Innovations Waiver is Medicaid program that provides home and community-based services to people with intellectual and developmental disabilities (I/DD). About 12,000 people in North Carolina receive the Innovations Waiver, and about 12,000 people are on the waiting list to get the waiver.

Local Management Entities/Managed Care Organizations (LME/MCOs) are the entities that administer North Carolina’s services for people with I/DD and/or mental health needs.

The Supports Intensity Scale is a tool that the LME/MCOs use to determine the supports an individual needs and the intensity of those supports. Innovation Waiver participants are assigned to Budget Categories based on their SIS results and several other factors. The categories go from A to G, with G representing the highest needs.

First, the amount of supports an individual gets must be based on medical necessity. An LME/MCO cannot say that a person is not eligible for a certain level of services because of the cost would exceed their assigned budget.

Second, employees with the LME/MCOs must encourage families to request all services they believe they need, regardless of the SIS score or assigned budget.

Third, when deciding whether to approve a request for services, the LME/MCO must only consider the needs of the individual. They may not deny services based on the assigned budget. They also must not deny services based on comparisons with other participants who have similar SIS scores or who are assigned to the same budget category.

LS v Wos Settlement Agreement

As the bulletin states, this guidance comes as a result of the LS v. Wos settlement agreement. Disability Rights NC filed this lawsuit in 2011 against the Secretary of the NC Department of Health and Human Services (NC DHHS). We were challenging the way the NC DHHS, acting through its contractor PBH (formerly Piedmont Behavioral Health and currently Cardinal Innovations), was implementing the Innovations Waiver.

That case was settled in 2015. Under the settlement, all LME/MCOs that provide services through the Innovations Waiver must take steps to ensure that all Innovations Waiver recipients:

  • Are empowered to request the services they need, in the amount they need them;
  • Understand that the Support Needs Matrix is a guideline and not a binding limit on services;
  • Are made aware of their due process rights; and
  • Understand their rights and responsibilities under the Waiver.

Unfortunately, some of the LME/MCOs failed to comply with the terms of the settlement agreement. So, in December 2017, we filed another complaint, this one called Rebecca B. v. Cohen (the current Secretary of NC DHHS). The new communication bulletin is in response to this complaint.