Update: Attention 1915(b)(3) Providers-Transition of 1915(b)(3) Codes

Issued: July 28, 2023

This is an update to a provider alert sent on July 10, 2023 (https://providers.partnersbhm.org/attention-1915b3-providers-launch-of-1915i-and-transition-of-1915b3-codes/.) The original alert is included below for your convenience.

The purpose of this provider alert is to update the Respite listing H0045 to break it out by child and adult. The new listing is here and has also been updated in the original chart.

 Provider Alert Sent on July 10, 2023:

Attention 1915(b)(3) Providers: Launch of 1915(i) and Transition of 1915(b)(3) Codes

Centers for Medicare & Medicaid Services (CMS) approved the 1915(i) State Plan Amendment (SPA) effective July 1, 2023. Like 1915(b)(3) services, 1915(i) services are home and community-based services (HCBS) which provide opportunities for Medicaid enrollees to receive services in their home or community rather than institutions. The approval was announced June 30, by the North Carolina Department of Health and Human Services (NCDHHS) in Medicaid Bulletin: https://medicaid. ncdhhs.gov/blog/2023/06/30/nc-medicaid-obtains-approval-1915i-state-plan-amendment.

Under 1915(i), NC Medicaid will continue to offer a comprehensive array of behavioral health, intellectual/developmental disability and traumatic brain injury (TBI) services to individuals in NC Medicaid Direct and the Behavioral Health I/DD Tailored Plan when it launches. The services will be available through the state’s six local management entities/managed care organizations (LME/MCOs) for individuals enrolled in NC Medicaid Direct, Tribal Option, all Tailored Plans (upon launch) and The Children & Families Specialty Plan (upon launch). Unlike (b)(3) services, an individual will not be required to meet an institutional level of care to qualify for HCBS.

What is happening?

The state was notified that CMS approved 1915(i) effective July 1, 2023. This means local management entities/managed care organizations will no longer provide services under the 1915(b)(3) authority. This will require some (b)(3) service codes to change. New (b)(3) codes are listed in this alert.

When is this happening?

It became effective July 1, 2023.

What services are available under 1915(i) SPA?

• Community Living and Support: focuses on skill practice/acquisition and provides supervision/assistance for activities. This service is available for members with an I/DD or TBI.
• Community Transition: provides funds for adult members moving from an institutional setting into their own private residence. This service is available for members with an I/DD, serious mental illness (SMI), severe substance use disorder (SUD) or TBI.
• Individual and Transitional Support: service supports in acquiring, retaining and improving self-help, social and adapting skills to reside successfully in the community. This service is available for some members with a serious emotional disturbance (SED), SMI or severe SUD.
• Respite: provides periodic or scheduled support and relief to the primary caregiver(s) from the responsibility and stress of caring for beneficiaries. This service is available for some members with I/DD, SED, severe SUD and TBI.
• Supported Employment: provides initial job training and development.  This service is available for members with an I/DD, SMI, SUD and TBI.

What are the changes from 1915(b)(3) to 1915(i)?

Because Behavioral Health I/DD Tailored Plans will operate under North Carolina’s 1115 demonstration, they will no longer be able to provide services under the 1915(b)(3) authority. To ensure that members maintain access to these critical services when Tailored Plans launch, NCDHHS is transitioning 1915(b)(3) services to 1915(i) services. With this transition, North Carolina is expanding the populations eligible for some of these services.

1915(i) does not require individuals to meet an institutional level of care in order to quality for HCBS. Services and supports may be offered to individuals before they need institutional care.

Partners will work with Tailored Care Management and providers to transition eligible (b)(3) members to 1915(i) SPA. As part of this transition, some (b)(3) services will have new codes.

How are (b)(3) codes changing?

Utilization Management will transition open (b)(3) authorizations to the new (b)(3) codes below. These new (b)(3) codes will automatically be added to the providers contract if they currently have the old (b)(3) code in their contract. The applicable base codes with corresponding modifiers under the (b)(3) benefit will also transition to the new code.

What must providers do?

Providers should not bill (b)(3) with the codes that end on June 30, 2023. Providers can resume billing once the new code is added to their contract.

1915(i) services will be added to provider contracts if they previously provided the equivalent (b)(3) service. If the provider had the equivalent (b)(3) service in their contract, they do not need to take any action.

If a provider wants to add/remove a service to/from their contract, they may complete the Provider Change Form.

What is the impact to members?

• NC Medicaid is committed to a smooth transition from 1915(b)(3) services to 1915(i) services.
  • Members currently receiving a (b)(3) service are the priority population to transition to 1915(i).
  • First priority will be for members moving to a Tailored Plan. (All Tailored Plan members will be transitioned to 1915(i) by Tailored Plan launch.)
  • Next priority will be for members in Medicaid Direct who are not moving to the Tailored Plan. (All Medicaid Direct members must be transitioned by June 30, 2024.)

• NC Medicaid intends that individuals will maintain their current (b)(3) services until they transition to 1915(i) services. 1915(b)(3) services will remain available for members who have been determined eligible for 1915(i) services but have not yet completed the 1915(i) services. This will allow time for providers to build capacity to provide these services.
• Members should contact their Tailored Care Manager (TCM) or care coordinator (if they opted out of TCM) if they want to receive a 1915(i) service. TCM will then complete an independent assessment and submit it to the state to determine if the member is eligible for 1915(i) services. If the member is eligible for 1915(i) services, TCM will complete a plan and submit it to Partners for prior authorization.

How can providers learn more about 1915(i)?

Providers can find more information on the transition from 1915(i) services to 1915(b)(3) services in the Transition of 1915(b)(3) Benefits to 1915(i) fact sheet. The fact sheet/Provider Playbook contains links to NCDHHS slides for Tailored Care Managers and providers.

Partners is developing a 1915(i) training webinar for members and providers. More details will be shared on this training once it is available on Partners Training website: (https://www.partnerstraining.org/).

Who should providers contact if they have questions?

Authorization or service-related questions: UMQuestions@partnersbhm.org

Provider contract questions: reach out to your Provider Network Specialist or email pas@partnersbhm.org.

Tailored Care Management questions: Tailoredcaremanagement@partnersbhm.org