Wednesday, July 11, 2012

Medicaid Waiver: NC Medicaid is now an HMO and Original Tenet of Mental Health Reform, CHOICE, Has Been Undone

Well, that's about the sum of it.  NC Medicaid re mental health is now an HMO.  Take it a step further: mental health services for Medicaid clients is now regulated as associated with NC having been granted, by the Feds, apparently, this Waiver .

So, we have Medicaid that has nothing to do w/ behavioral health services that has NO Waiver restrictions; and then we have the discrimination of this 1915bc Waiver as pertaining to mental health services. 

That doesn't seem quite right and it seems to me that is not in keeping with the NC law that was passed a few years ago disallowing such discrimination.  But I'll have to review that.

The excuse that WHN LME is using in order to bar me from being an In-Network provider is that I turned in my application two weeks late.  However, what can also take place for any Medicaid provider over the first year as being a provider In-Network to any of the LME's, is that they can discard you.  Its like being on probation for a year.  And I would not be surprised if they can continue to do that, thus completely silencing all the providers from saying anything negative about the LME's AT ALL.

Here is the letter I received from Bill Bullington at NC DHHS; he is the liason w/ the LME's:


"Dr. Hammond, you are incorrect that Medicaid requires the network to be open for one year. Rather, there was a meeting between DMH and DMA in which it was considered appropriate, that for the first year, an enrolled provider could only be terminated from the LME/MCO network "for cause" (based on performance, fraud/abuse, monitoring results, etc). This consideration only applied to those enrolled in the network prior to the LME/MCO go live date.

My understanding is you did not comply with the open enrollment process offered by Western Highlands and therefore were not an enrolled provider in their network as of Jan. 3, 2012. Western Highlands provided an open enrollment period allowing more than sufficient time for eligible providers to complete, submit and become enrolled as a network provider prior to Jan 3, 2012. Applications received after that date had no guarantee of being reviewed or processed.

After Jan 3, 2012 Western Highland began operating as an LME/MCO which includes the ability to close or open their network based on service need and the ability to terminate a provider from their network based on the consideration stated above.

I hope this provides you with sufficient clarification regarding your issues and the roles and responsibilities of providers and LME's in meeting established deadlines necessary to successfully complete and participate in the 1915 (b) (c) Wavier process.

Here is the link to the waiver which certainly deserved investigating:


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