DATE: February 23, 2005
SUBJECT: Piedmont Cardinal Health Plan
DISTRIBUTION: County Directors of Social Services
Medicaid/NC Health Choice,
Food Stamp Supervisors and Caseworkers
Medicaid Program Representatives
Adult Program Representatives
Work First Representatives
The State of North Carolina has received approval from the Centers for Medicare and Medicaid Services (CMS) to operate a capitated waiver program which includes all Medicaid Mental Health, Developmental Disabilities, and Substance Abuse Services (MH/DD/SA) in a five-county area. These counties are: Cabarrus, Davidson, Rowan, Stanly and Union counties.
Piedmont Cardinal Health Plan (PCHP), also known as Piedmont Behavioral Healthcare, is the public MH/DD/SAS local management entity (LME) that will operate the capitated waiver program. PCHP will enroll with DMA as a prepaid health plan and DMA will pay PCHP a flat amount monthly for each Medicaid recipient in the five counties. In turn, PCHP will be responsible for providing and paying for all MH/DD/SA services for these Medicaid recipients who live in one of the five counties.
This also includes intermediate care facilities for the Mentally Retarded (ICF-MR), Psychiatric Residential Treatment Facility (PRTF), Community Alternatives Program for the Mentally Retarded - Developmentally Disabled (CAP/MR-DD), and Inpatient Psychiatric Care.
One of PCHP’s primary goals is to deinstitutionalize or divert people from going into an institution and provide their mental health services in a community-based environment if feasible and desired by the individual.
PCHP also hopes to be able to serve more Medicaid recipients at no additional cost through increased local control of MH/DD/SA services and funding.
The capitated waivers that have been approved are:
This includes recipients living at home who require mental health services age 3 or older.
This includes recipients who are mentally retarded or developmentally disabled and require care as an inpatient in a nursing facility setting.
Psychiatric Care is also a covered benefit under this waiver.
This includes recipients who can safely remain at home with care providers. If a recipient is currently receiving CAP-MR/DD services he will continue to receive these services through Innovations.
Innovations are self-directed; the consumer has more control in hiring and supervising his/her individual care providers. This will apply to persons of any age. CAP codes will remain the same.
Recipients must access all mental health, developmental disability, PRTF, inpatient psychiatric care, ICF-MR, substance abuse services and Innovations (formerly the CAP/MR-DD program) from Piedmont (PCHP).
Charges incurred prior to April 1, 2005, can be applied to the ongoing deductible.
Apply the old bill policy to these charges.
Retroactive participation is an allowable benefit only with the Innovation program services.
In addition there will be a “P” indicator on the Individual Medicaid segment (IE)
in EIS to identify the PCHP member. This is a new field that will be added to the
Any recipient who is a resident of the 5 county region requesting ICF-MR or Innovation services should be directed to call PCHP at 1-800-939-5911.PCHP will complete the prior approval and arrange these services for eligible recipients.
Do not deny an application without calling PCHP at 1-704-721-7000 to verify
The status of the Piedmont level of care (LOC) determination for Innovations or ICF-MR services.
Include individuals residing in the 5 county region in authorized status (all living arrangements) in the following aid program/categories. See III.B. below for exceptions.
Example: Third birthday is in February. Child is identified as PCHP effective March.
A new field has been added to EIS on the Individual Eligibility (IE) screen. A “P” indicator in a segment on the IE screen identifies the individual as a PCHP member for those months. The PCHP-1 notice (see figure 1) is sent to the casehead informing him that mental health services are provided through PCHP.
On the night of March 15, 2005, (the night prior to SSI Medicaid regular run), EIS automatically adds the P indicator to the IE of all Medicaid recipients who are a PCHP participant in the 5 county area.
The indicator is being added to EIS prior to April 1, 2005, in order for the April Medicaid cards to contain the Piedmont information.
Beginning March 16, 2005, EIS:
When a Medicaid recipient transfers to one of the affected population aid program categories/classifications, EIS automatically adds the P indicator to the IE segment for the ongoing month.
When a Medicaid recipient transfers out of an affected population aid program category/classification, EIS automatically deletes the P indicator from the IE segment for the ongoing month.
Individuals that are placed out of the county of residence for residential care, long term care, foster care, or adoption assistance are still considered to be part of PCHP.
EIS still shows one of the five counties as the county of residence. The services provided under the waivers must be coordinated through PCHP.
NCHC is an excluded program unless the NCHC case transfers to Medicaid. Once the transfer is effective in a PCHP county, the case will be PCHP effective the ongoing month and a notice (PCHP-1) will be mailed to the casehead informing him how to access PCHP services.
If the Medicaid case is in the incorrect county of residence because the SDX shows the wrong county:
When the county number is corrected in EIS, EIS:
Once the deductible is met, PCHP pays for the services included in the Plan of Care.
The PCHP-1 notice informs Medicaid recipients that mental health services are provided through PCHP. The letter includes a statement that a child under age 3 receiving Medicaid in the case is not included as a PCHP enrollee.
EIS sends the PCHP-1 notice to the casehead, including SSI recipients living in the five county region served by PCHP when EIS adds the P indicator to the IE for an individual on the case. This occurs:
There is a report in NCXPTR (DHRWDB PIEDMONT HEALTH PLAN NOTICES) listing the cases sent the PCHP-1 notice.
For county transfers from a Piedmont county to a non-Piedmont county, EIS sends a PCHP-2 notice to the casehead alerting him that during the county transfer, recipients continue to be PCHP enrollees. The recipient must contact PCHP to arrange for his mental health services during the transition period.
There is a report in NCXPTR (DHRWDB PIEDMONT COUNTY TRANSFER NOTICES) listing the cases sent the PCHP-2 notice.
The case information appears under the new county on the report.
Caseheads may receive more than one notification at different times if the PCHP indicator is deleted and later added.
During the recipient’s first continuing need review (CNR), PCHP initiates the level of care determination using their own Piedmont LOC form (see figure 3), and furnishes the county with a copy once approved.
PCHP uses the Piedmont Level of Care LOC form instead of the existing MR-2.
The county dss can assist individuals who are unable to arrange for services.
The state will mail a letter (PCHP-1) to him upon approval of his application as to how to request mental health services and the importance of only contacting PCHP for those types of services.
At redetermination the worker will remind the recipient to contact PCHP if he needs any mental health services and the importance of only contacting PCHP for services.
PCHP enrollees and applicants can call PCHP customer service directly at 1-800-939-5911 for any questions regarding PCHP or to request mental health services. Counties can reach the PCHP administrative offices at 1-704-721-7000.
The mailing address for prior approval is:
Piedmont Behavioral Healthcare
528 Lake Concord Road
Concord, North Carolina 28025
Please address questions concerning this letter to your Medicaid Program Representative.
(This material was researched and written by Renee Carlton-Pettiford, Policy Consultant, Medicaid Eligibility Unit).
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.