Like many health plans, and all Medicaid managed care plans across the country, Smoky operates a closed provider network, which means that Medicaid beneficiaries enrolled in the plan can only receive services from providers who are credentialed and contracted to participate in Smoky's network. The only exceptions are for emergency services or when there is no network provider available to provide medically necessary covered services to a particular individual. This is no different than someone having to choose between in-network physicians in a private PPO or HMO. Smoky's closed network is designed to promote quality services, maximize public resources and ensure financial stability and sustainability of providers participating in the Medicaid managed care plan.

Smoky's authority to operate the closed network stems from federal regulations and our contract with the N.C. Department of Health and Human Services (DHHS). The federal regulations applicable to Medicaid managed care are found at 42 CFR Part 438. Specifically, 42 CFR § 438.206(b)(1) states that MCOs are required to "maintain and monitor a network of appropriate providers that is supported by written agreements and is sufficient to provide adequate access to all services covered under the contract [with DHHS]." DHHS monitors the adequacy of our network through the annual gaps analysis and needs assessment.

Section 7.6 of the Medicaid contract between DHHS and Smoky explicitly states that Smoky "shall have the authority to operate a Closed Network and shall not be required to review the qualifications and credentials of Providers that wish to become Network Members if the Network has sufficient numbers of Providers with the same or similar qualifications and credentials to provide adequate access to all services covered under this Contract in accordance with 42 CFR 438.206." The contract goes on to state that Smoky "shall have the sole discretion to determine provider participation in the PIHP Closed Network, including determinations regarding contract renewal and procurement, subject to the requirements of this Contract and federal regulations."

Smoky makes contract renewal decisions in accordance with written selection and retention criteria as required by 42 CFR § 438.214, which states that MCOs are required to implement "written policies and procedures for selection and retention of providers." Because we believe in transparency, our provider selection and retention policy was discussed with the Provider Advisory Council in August 2014 and posted to the Smoky website for comment for 30 days in September 2014, even though this is not a requirement of federal regulation or our contract with DHHS.

We have talked a lot about comprehensive care centers as an important cornerstone of our system of care. Using the term community mental health centers, people have been talking about this concept for more than 50 years. The basis for this successful model is that there should be a well-known portal with a range of services under one roof. Smoky has merely renamed the model and updated it to better meet both provider and consumer needs in present day western North Carolina. Many things have changed in 50 years, but the model itself remains strong and especially relevant to a system of care that has undergone so much upheaval through the process of mental health reform. 

Our selection and retention policy includes an attachment that describes the many clinical advantages associated with the model. The Substance Abuse and Mental Health Services Administration (SAMHSA) has also recognized the value of this model and used it as the foundation for the proposed Certified Community Behavioral Health Clinic designation.

How does this model influence contracting choices? It allows Smoky to carefully manage the mix of services with payor sources such as Medicaid, federal block grant and state and local funds.

Smoky is responsible for managing the care for both individuals with Medicaid and those who are uninsured or underinsured, and there are great differences in the funding for those two populations. In the unmanaged open network that existed before the waiver, providers could deliver high-margin enhanced services without offering a full continuum of care, such as crisis and walk-in services, or services for the uninsured. The comprehensive care center model allows for balance to be achieved between high-margin services with those that have much less robust revenue streams or even negative/loss margins but are critical to the care of individuals who are uninsured or underinsured. This helps us maintain the stability of the provider network and support a model that ensures access to care for all consumers, regardless of an individual's ability to pay. This supports the ability of the provider to be the "safety net" provider so critical in our system of care.

Do you or does someone you know use drugs? Do you know about North Carolina's 911 Good Samaritan Law?

 

The 911 Good Samaritan Law protects people who witness an overdose - or overdose themselves - from being criminally prosecuted for minor amounts of drugs, paraphernalia or underage drinking if they call for help. The law also states that doctors who prescribe naloxone, a medication that reverses an opiate overdose, and bystanders who administer naloxone cannot be held liable in civil court. Additionally, it allows community organizations to dispense naloxone under medical guidance.

 

The N.C. Harm Reduction Coalition is conducting a survey to find out how people use the law. Access the survey online. 

The rally will take place from 10 a.m. to 2 p.m. on Saturday, September 19, at the Open Air Gym at Lake Junaluska. Part of National Recovery Month, the event is designed to celebrate and raise the profile of recovery by showing friends, neighbors, policymakers and the media that people can achieve recovery and live a healthy life.

Organizers are also seeking nominations for the 2015 Recovery Champion of the Year awards. Nominations are open to adults in recovery for at least one year. Nominees must consent to the nomination or self-nominate (no one in recovery should ever be 

"outed" without their knowledge and consent).

Separate nominations for recovery "allies" are open to employers, businesses or organizations. Download a nomination form here. For more information, contact Richie Tannerhill, Smoky Peer and Family Support Specialist, at 1-800-893-6246, ext. 1157, or at richie.tannerhill@smokymountaincenter.com. 

On June 2, the N.C. Court of Appeals issued a unanimous decision upholding Smoky's actions in a case involving the 84-hour weekly service limit in the N.C. Innovations Waiver for adult participants. Smoky denied a request from a participant who asked for services in excess of that limit. This denial was upheld by Administrative Law Judge Robin Anderson at the Office of Administrative Hearings, and later by Wake County Superior Court Judge Michael Morgan, before being appealed to the Court of Appeals. 

 
The decision also clarifies the process for reviewing claims brought under the Americans with Disabilities Act. The appeals court found the determination of whether a "significant risk of institutionalization" exists under the ADA is "fact-intensive and is affected by numerous variables" but that the central question is "whether the reduction in (services) will likely cause a decline in health, safety, or welfare that would lead to the individual's eventual placement in an institution."

In this case, the court found that any significant risk of institutionalization was both speculative and, if it materialized, was not due to any action of Smoky. We believe this decision provides important clarity for MCOs and for Innovations participants, and we are deeply grateful for the superior legal representation we received from the North Carolina law firm of Nelson Mullins on this matter. The decision is captioned Short v. N.C. Department of Health and Human Services and Smoky Mountain Center, No. COA14-1042, and has been approved for publication.

For more information about this case, contact Tracy Hayes, Smoky General Counsel, at 828-225-2785, ext. 1267, or legalandcompliance@smokymountaincenter.com.

State lawmakers in Raleigh continue to work on finalizing North Carolina's spending plan for the current fiscal year. About two-thirds of the entire legislature plans to meet to reconcile differences in the House and Senate budgets. Stay tuned.

Meanwhile, Governor Pat McCrory's administration has founded a new, 18-member task force on mental health and substance use issues. The group will evaluate how to improve the current service delivery system, reduce stigma and examine how the judicial system can better serve people with mental illness, among other charges. Members will send McCrory recommendations by May 2016. Other statewide developments include:

• The N.C. Department of Health and Human Services (DHHS) announced that four LME/MCOs have been selected to pilot Critical Time Intervention (CTI), a part of the state's Crisis Solutions Initiative. CTI helps adults with mental illness who are transitioning, for example, to housing from homelessness, or from institutional to community-based services. The first LME/MCOs to implement CTI will be Alliance Behavioral Healthcare, CoastalCare, Partners Behavioral Health Management and Cardinal Innovations Healthcare Solutions. Read more.
• DHHS has received a $7.8-million Access to Recovery grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) to help more than 4,000 people with substance use disorders access recovery support services. Read more.