The North Dakota 1915(i) SPA provides a range of a services (including care coordination, supported employment, and non-medical transportation) and state officials view this set as an inter-related package of services to be deployed based on beneficiary need. However, a particularly innovative feature of the SPA is the state’s approach to housing for people with behavioral health needs. Two of the covered services are directly related to helping members obtain and sustain community housing.
- Housing Support Services. Members who are experiencing or at risk of homelessness or who are not suited to live in an institutional setting may receive up to 156 hours each of pre-tenancy and tenancy services each year and may receive up to 25 percent of these services via remote support each month. The payment rate for these services is $10.70 per 15 minutes.
- Pre-tenancy supports help individuals secure housing and include assistance with benefits applications, a housing search, or lease applications.
- Tenancy supports help individuals sustain housing and include financial literacy training, education on tenant rights, skills training, and dispute resolution.
- Community Transition Services. Beneficiaries who have lived in an institution for at least 30 days, are planning to move into a community setting and are likely to qualify for the 1915(i) program once they leave the institution may be eligible for community transition services. These services cover up to $3,060 of non-recurring costs related to moving into a private residence (e.g., security deposit). Since a beneficiary cannot participate in the 1915(i) program while living in an institution, the cost of these services cannot be billed to Medicaid until the beneficiary leaves the institution. If the beneficiary does not ultimately qualify for 1915(i) services the provider will still be reimbursed, but the Medicaid agency will record those costs as an administrative cost and not a service cost. (The federal government pays a smaller share of Medicaid administrative costs than it does of Medicaid service costs.)
Remote services: Helping members living in rural areas access services
“It [remote services option] is another avenue due to the ruralness of our state to provide services to individuals to meet their needs”
Each month members may receive some support services remotely, including up to 25 percent of housing support services. Remote services must be provided via a Health Insurance Portability and Accountability Act (HIPAA) compliant platform, including telephone or video conferencing. State officials emphasized that remote services are designed for the benefit of the member, not the provider. Although these services are more broadly available, state officials envision this option being particularly useful in case of a crisis, such as a weather emergency or return to use by someone in recovery from a substance use disorder. Officials believe that the remote option will make it easier for members to reach out to their providers for assistance and enable providers to deliver care when travel is difficult. They also believe that the policy may make it easier for members who are concerned about being stigmatized to access services as they can do so from home instead of being seen to enter an office. This might be especially important in a small community. This option is intended to be used only when there is an existing relationship between the member and the provider. Thus, initial visits must be provided in person, but check-ins and consultations may be provided remotely. North Dakota has established other requirements for this option including that the member must choose to receive the services remotely and the services must not block the individual’s access to the community.
Care coordination: the heart of service authorization
“It is the care coordinator who determines the needs of the individual to determine which services they qualify for.”
North Dakota Medicaid requires providers to obtain a service authorization before providing 1915(i) services and this process is embedded within the care coordination service. After a beneficiary is found to be eligible for the program, the member works with a care coordinator to develop a person-centered plan of care (POC) based on information from the member, the member’s parent or guardian (if applicable), and other people in the member’s life. A member’s POC specifies the amount and duration of all 1915(i) services the individual is to receive. The POC also specifies the member’s choice of providers. (Care coordinators confirm selected providers’ availability as part of POC development.) The POC and provider information is submitted to the State Medicaid agency or MCO for approval. Approval of the POC constitutes pre-approval of the services. The care coordinator notifies the individual service providers that the POC has been approved, and these providers then use that information to obtain service authorizations for each service they are to provide to the member.
At the start of the program, state officials had hoped to purchase a system that would automate many of the program functions. However, there wasn’t sufficient funding in the existing appropriation to purchase the entire system, so an internal eligibility system was developed, and the case management functions are currently paper-based. The state integrated service authorizations and claims into the state’s MMIS. Funding for the case management system was approved during the recent legislative session and the state is in the process of working with the vendor to build the system. While there are benefits to operationalizing a 1915(i) program prior to purchasing a system, state officials advise others seeking to establish a 1915(i) program to consider the funding and time necessary to develop the systems needed to administer the program. Stakeholders suggest that states minimize complexity in their eligibility and service authorization processes to make it easier for qualified beneficiaries to access services.