An Institution for Mental Disease (IMD) is defined in section 1905 (a) of the Social Security Act as "a hospital, nursing faciity, or other institution of more than l6 beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases (mental illness or substance abuse) , including medical attention, nursing care and related services".  This rule applies to those between the ages of 21 and 64.   Medicaid does not cover costs for adults with mental illness in an IMD, therefore, if it is established that these homes are meeting IMD status, it results in discontinuance of medicaid coverage for those within the facility.  They lose their health insurance!

Normally, we think of this as meaning medicaid won't pay for those in freestanding psychiatric hospitals- like the state hospitals, Holly Hill, and Old Vineyard and others.  So although this is an old rule, it is new in that it is being applied to the Adult Care Home Industry.

How Did we Get Into This Mess?

For years, North Carolina has had study commissions, bill proposals and the like to develop more housing options for those with mental illness.  It is well known that many people have had to turn to Adult Care Homes (rest homes)  of over l6 beds because there are no appropriate alternatives.  Many concerns have been raised over the co-location of those with mental illness who may be younger, with residents who are younger.  We have a highly effective Housing 400 program, but it simply does not extend to help enough people.  We need a continuum of residential options- from more restrictive, highly staffed, to group homes, to scattered apartments, and to include supportive housing and independent housing with flexible supports. 

How Big is the Problem?

NC has about 38 large adult care facilities (that are more than l6 beds) that the state believes may have more than 50% of the residents who have diagnoses of MI or SA- making them subject to the exclusion.  We hear that there may be as many as 1200 people subject to this exclusion.  If you are someone who is very satisfied with your placement, you may not be able to stay there, despite how appropriate it may be.  If you are someone who ended up living there because there was a lack of other options, this may present an opportunity for you.

What is the State Planning to Do About this?

1. Discuss with stakeholders
2. Identify adult care homes that may meet the IMD exclusion definition
3. IDentify residents needing assessment
4. Conduct Assessments through the Local Management Entties and the CABHAS
5. Include resident specific housing assessment with options
6. Report these findings to the federal government
7. Develop housing plan and implement

What are some of the other Housing Options within NC?

• Licensed group homes (.5600) -
• HUD 811 Group Homes or apartments
• Public Housing Units and Section 8 (cash assistance/voucher for housing)
• Section 8 only (voucher to help pay for housing)
• Targeted housing units (low income housing tax credit)
• NC Housing search  http://nchousingsearch.org/ is a great option for searching online for housing - Nina Fedele is the contact person.  You can also use this site if you want to post available units
• Local Family Care Homes

What are the Questions?

• It's' not really been determined legally whether adult care homes comply with the IMD exclusion - negotiations ongoing with CMS.  After all, the facilities aren't licensed as psychiatric facilities, nor do they specialize in care and treatment of psychiatric disorders.  Their specialty is basic room and board - basic care.
• When will the assessments start?  We had heard July, but it is nearly August, and we don't believe they have started.
• What if your loved one doesn't want to leave- will they have a choice to be part of the less than 50% population remaining?
• What if there simply isn't enough housing?  Will the state hospitals serve as a safety net?

 What Can You Do?

1.  Write a Letter to the Editor
2. Call your federal legislator and tell them that it is time to fix this old, outdated law.  Medicaid is an insurance program and should pay for a variety of appropriate options- there should be no exclusions
3. Call your state legislators and say we must have an immediate allocation of dollars to create
4. Call the Centers for Medicare and Medicaid Services at the national level and say we must have more time to work out a plan in NC

Talking Points 

This issue is one that really points the finger at the problem- our state's failure to fund adequate housing for those living with severe mental illness.  We need a full continuum of residential services.  Ironically, several years ago the state discouraged facilities from mixing those with mental illness with the aged population in rest homes; what resulted is the 38 facilities with a large proportion of people with mental illness!  And those homes that really worked to provide the right treatments really show up on the billing surveys when they are doing the right thing for their population.  But there are other heartbreaking stories - young people who live in rest homes with groups primarily in their 80's, not by choice, but by a lack of reasonable, appropriate housing options.

Let's turn this tragic turn of public policy into an opportunity to develop the right services - a residential continuum- for those with mental illness.  Let's exercise the strength of the grassroots (See What Can You Do?)

Deby Dihoff, MA

Executive Director