Provider Manual Updated
In anticipation of the launch of Behavioral Health and Intellectual/Developmental Disability (I/DD) Tailored Plans on Dec. 1, 2022, the Department continues to work on the design and implementation of the Tailored Plans and the provision of Tailored Care Management (Tailored CM). NC Medicaid is releasing an updated Tailored Care Management Provider Manual to reflect changes to the Tailored CM model since the updates released on April 21, 2022. Notable changes include updates to the Tailored CM staffing qualifications and Data and Security updates.
Guidance on Care Manager Qualifications
This is an updated version of previous guidance released on April 21, 2022. This guidance provides an update to the minimum qualifications for Care Managers.
- Care Managers for Tailored CM may now meet North Carolina’s definition of Qualified Professional (QP) per 10A NCAC 27G .0104
- *Full-time Mental Health/Developmental Disabilities/Substance Abuse Services experience required for credentialing as a Qualified Professional may be obtained before or after obtaining the educational degree.
- See Request to Renew a Waiver of Rules 10A NCAC 27G .0104 and 10A NCAC 28A .0102 Memo (Dated Feb. 25, 2022)
- Care managers need to have care coordination, care management, or case management experience. Experience is inclusive of care management/case management/care coordination assessment, treatment planning/Person Centered Plan (PCP)/Individualized Service Plan (ISP) development, referral, and follow-up and any of the other requirements of the functions/services that a Tailored CM care manager must provide. Providers are responsible for ensuring that the people they hire have sufficient experience that mirrors the required care management functions in the policy.
Guidance on Behavioral Health Care Manager Supervisor Qualifications
This is an updated version of previous guidance released on April 21, 2022. This guidance provides an update to the minimum qualifications for Behavioral Health Care Manager Supervisors for Tailored CM. Supervising care managers serving members with behavioral health conditions may now have the following minimum qualifications:
- A license, provisional license, certificate, registration, or permit issued by the governing board regulating a human service profession including Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Clinical Addiction Specialist (LCAS), Licensed Clinical Mental Health Counselor (LCMHC), Licensed Psychological Associate (LPA), or a Registered Nurse (RN) license issued by the North Carolina Board of Nursing.
- Three years of experience providing care management, case management, or care coordination to the population being served.
Guidance on Intellectual Developmental Disabilities / Traumatic Brain Injury Supervising Care Managers Qualifications
This is an updated version of previous guidance released on April 21, 2022. This guidance provides an update to the minimum qualifications for Intellectual Developmental Disabilities (I/DD)/Traumatic Brain Injury (TBI) Supervising Care Managers for Tailored CM. Supervising Care Managers serving members with an I/DD or a TBI must have one of the following minimum qualifications:
- A Bachelor’s degree and five years of experience providing care management, case management, or care coordination to complex individuals with I/DD or TBI; or
- A Master’s degree in a human service field and three years of experience providing care management, case management, or care coordination to complex individuals with an I/DD or a TBI.
Care Manager Extenders (Removal of Full Time Equivalent Extender Limits and Clarification of Supervision Requirements)
This is an updated version of previous guidance released on April 21, 2022. This guidance is an update to clarify the working relationship between Care Managers and Care Manager Extenders. Language has been updated to note that work of extenders must be directed, not supervised by the Care Manager. It is the expectation that the Care Manager and the Care Management Supervisor can direct all care management supports for members to ensure that all services are well coordinated.
- Updated language: The care management functions of an extenders must be directed by the Care Manager at an Advanced Medical Home plus (AMH+) practice, Care Management Agency (CMA), or Tailored Plan. The extender cannot work for the same organization where they receive services.
- Additionally, the manual will be updated to allow more flexibility in the number of FTE extenders that a Care Manager may work with.
- The following language has been removed from the provider manual: A Care Manager may not supervise more than two FTE extenders.
Phased Assignment Approach for Tailored Care Management Providers
To ensure that providers certified as AMH+ practices and CMAs are ready to provide Tailored CM services to members both at Tailored Plan launch and ongoing, the Department is introducing a second readiness and contracting milestone as part of a phased assignment approach. The intent of the second milestone is to allow additional time for providers who are not able to pass readiness by Sept. 30, 2022, to have a date to complete readiness with a standard date of member assignment and program launch. All providers that pass readiness prior to Sept. 30, 2022, will be contracted and receive assigned members for the Dec. 1, 2022, launch.
- Providers that pass their National Committee for Quality Assurance (NCQA) readiness review and contract with Tailored Plans by Sept. 30, 2022, will be included in Tailored CM auto assignment for Dec. 1, 2022, launch.
- Providers that pass their NCQA readiness review and contract with Tailored Plans by Dec. 31, 2022, will be included in Tailored CM auto assignment for the Feb. 1, 2023, launch.
- Please note, providers that complete readiness and contract with Tailored Plans following the Sept. 30, 2022, milestone will be included in the Tailored Plan and Enrollment Broker provider directories and available for member choice on a rolling basis and following the standard timelines.
Twenty-Four-Hour Coverage for Tailored Care Management Providers
AMH+ practices and CMAs must arrange for coverage for services, consultation or referral, and treatment for emergency medical conditions, including behavioral health crisis, 24 hours per day, seven days per week. This requirement includes the ability to (1) share information such as care plans and psychiatric advance directives, and (2) coordinate care to place the member in the appropriate setting during urgent and emergent events. AMH+ practices and CMAs do not need to be the first responders if a member has an emergency medical condition or a behavioral health crisis. Automatic referral to the hospital emergency department (ED) for services does not satisfy this requirement.
Data and Security Updates
AMH+ practices, CMAs, and clinically integrated networks (CIN) or other partners involved in Tailored CM will be expected to comply with all federal, state, and Department privacy and security requirements regarding the collection, storage, transmission, destruction, and use of data including Medicaid claims and encounters. AMH+ practices and CMAs will be considered covered entities and must comply with the terms of the NC Provider Agreement, including HIPAA requirements, and meet the following requirements:
- Must be an active and enrolled NC Medicaid provider
- Must be providing Medicaid services or care management to Medicaid beneficiaries
- Cannot be providing any administrative or IT services to other providers outside of their practice
CINs or other partners must submit necessary security documentation. A covered entity is responsible for ensuring their sub-subcontractors are meeting the necessary security requirements.
Security Documentation Required by Clinically Integrated Networks or Other Partners
The following security certifications and assessments meet the requirements:
- Year 1 only – NIST 800-53 Rev 4 or Rev 5 self-assessment. The Department has a NIST 800-53 Rev 4 self-assessment document available which will act as the baseline assessment. The plans can require more extensive documentation. A self-assessment cannot be accepted for year 2 and beyond. Please note that if a provider is new to the organization after year 1, the self-assessment can be accepted for year 1 of that relationship. After that a self-assessment can no longer be accepted.
- Soc 2 Type 2 (Must include all five trust areas)
- HITRUST - Since HISTRUST is a two-year certification, DHHS will accept the completed certification for year 1, and the engagement letter indicating a recertification is planned for year 2
- ISO27001 - ISO 27001 certification is acceptable – however the Federal agencies in the future may change to a NIST based assessment only in the future. Vendors seeking an ISO 27001 certification may need to go back and pursue another acceptable certification or assessment in the future.
For infrastructure providers such as AWS, Azure, or Google or other IPaaS or IaaS providers, a SOC 2 Type 2 report from the provider is acceptable for the infrastructure components of the solution. This does not cover the application components of the solution.
For additional information, please see the Tailored Care Management webpage.