NASHP

How North Dakota Uses 1915(i) to Provide Supportive Services to People with Behavioral Health Conditions in Rural Areas

November 1, 2021 / by Neva Kaye

State Medicaid agencies recognize that meeting beneficiaries’ social needs (e.g., housing) is important to improving overall health outcomes, especially for individuals with chronic health or behavioral health conditions.

A few states, such as North Dakota, have begun to leverage federal Medicaid’s 1915(i) state plan authority to meet the social needs of people with behavioral health conditions. North Dakota’s 1915(i) program focuses on beneficiaries with behavioral health conditions, seeks to address priority social needs (including housing), and incorporates policies designed to meet the challenges of serving program members living in rural areas.

To learn more about North Dakota’s experience, NASHP staff conducted research and engaged North Dakota officials.

Background: What Is 1915(i)?

The 1915(i) option was created by the Deficit Reduction Act of 2005 (DRA) and modified by the Affordable Care Act (ACA) in 2010. This provision of the Social Security Act allows states to provide home and community-based services (HCBS) under the Medicaid state plan by obtaining approval from the Centers for Medicare & Medicaid Services (CMS) of a state plan amendment (SPA). The SPA must specify the criteria that beneficiaries must meet to qualify for services, what services will be covered, the price the state will pay for each service, the qualifications that providers need to meet to provide each service, and more. CMS has issued regulations implementing this provision, as well as guidance for states considering a SPA and a standardized form that state can use to prepare the SPA.

Key differences among the 1915(i) home and community-based services state plan option, 1915(c) home and community-based waivers, and 1115 demonstration waivers

Prior to 1915(i)’s enactment, states could only cover HCBS under a 1915(c) home and community-based waiver or an 1115 demonstration waiver. Both types of waivers are time-limited and states may not spend more federal funding to provide services under either waiver than they would have spent absent the waiver (“budget neutrality”). In addition, beneficiaries must need a level of care that would qualify them for institutional care before qualifying to receive HCBS services under a 1915(c) waiver. Also, SPAs do not expire, although 1915(i) SPAs that target a specific population (e.g., beneficiaries with behavioral health conditions) do have to be renewed every five years.

Waivers offer states several tools to manage enrollment (and thus total cost) that are not available under a SPA. States may cap the number of beneficiaries who participate in the waiver, place beneficiaries who qualify for services on a waiting list and choose to offer the services only in some parts of the state. Under a 1915(i) SPA, states must allow all Medicaid beneficiaries who qualify for the services to access the services. States do, however, set eligibility requirements that beneficiaries must meet to receive services, and these requirements govern enrollment and cost. These criteria may consider an individual’s, diagnosis, functional ability, and other factors that indicate need. States with approved 1915(i) SPAs may adjust those criteria by submitting an amendment to CMS for its review and approval.

North Dakota’s 1915(i) Program: An Opportunity to Address Gaps in Care

The US Census Bureau estimates that North Dakota’s population was less than 800,000 in 2019. North Dakota is sparsely populated and has widespread workforce shortages. Of its 53 counties, all but twelve contain designated primary care health professional shortage areas (HPSAs) and all but five are designated as mental health HPSAs. This environment creates a strong incentive for North Dakota to develop innovative strategies for supporting Medicaid beneficiaries with serious behavioral health conditions, especially those living in rural areas.

In 2017-2018, the North Dakota Department of Human Services (DHS) commissioned an analysis of North Dakota’s behavioral health system resulting in the development of a strategic plan for systems change.  The analysis identified gaps in community-based services, particularly those that address social determinants of health. DHS leadership was committed to addressing these gaps and set securing the Medicaid 1915(i) SPA as a target strategic goal.  In 2019, North Dakota’s legislature authorized its Medicaid agency to pursue that goal. (§43 of North Dakota Senate Bill No. 2012.) The legislature also appropriated about $9.4 million in ongoing funding to pay for services and administration, including three staff (two in the Medicaid agency and one in the behavioral health agency). Program staff estimated that the funding is sufficient to cover 11,000 beneficiaries (referred to as program members) over five years. CMS approved the SPA in January 2021, and the program launched in February 2021.

Developing the SPA: Stakeholder input strengthened the program

“We took their [stakeholder] feedback on what services we should cover, who the SPA should serve, and provider qualifications and payment. Then we implemented what we could within CMS regulations.”

Program administrator

The DHS’s Medicaid and Behavioral Health divisions collaborated to develop the 1915(i) SPA. Program administrators sought extensive stakeholder input throughout SPA development. Staff from the two divisions convened five public meetings held throughout the state, posted the draft application to the state website, and held a webinar reviewing the draft application. Program staff reported that hundreds of stakeholders attended the meetings, including consumers, medical providers, and housing providers. Their input had a major impact on program policies, including service coverage (Table 1) and adoption of several policies that would enable the program to function better for members living in rural areas (e.g., allowing members to receive services remotely). State officials report that the strong stakeholder support built through this process was critical to securing CMS approval of these policies.

Table 1: North Dakota’s 1915(i) Program Covers 12 Services Chosen to Fill in Gaps in Community-Based Services

1.     Care Coordination

2.     Training and Supports for Unpaid Caregivers

3.     Community Transitional Services

4.     Benefits Planning

5.     Non-Medical Transportation

6.     Respite

7.     Prevocational Training

8.     Supported Education

9.     Supported Employment

10.   Housing Support Services

11.   Family Peer Support

12.   Peer Support

Source: North Dakota DHS. 1915(i) Services. https://www.behavioralhealth.nd.gov/1915i/services

Key Policy Lever: Eligibility Policies Govern and Manage Enrollment

To qualify for services under this 1915(i) SPA, a Medicaid beneficiary with a behavioral health condition must have an income of no more than 150 percent of the federal poverty level (FPL), meet functional need criteria, and reside in and receive services in the community. North Dakota has further defined three of these requirements (Table 2).

Table 2: How North Dakota defines and implements three key beneficiary eligibility requirements

Requirement Behavioral Health Diagnosis Functional Need Community Setting
Definition Diagnoses of mental illness, substance use disorder, and brain injury An impairment, which substantially interferes with or substantially limits the ability to function in the family, school or community setting
Implementation List of qualifying diagnosis codes Score at least 50 points (out of a possible 100) on the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)1

1 The WHODAS 2.0 is the assessment instrument North Dakota has chosen to use to measure functional need.

“How you determine your eligibility criteria is very important. We budgeted for 11,000 over 5 years… We’ve taken our best informed guess about where to set the eligibility level. We may find out it is too high. Then we will ask CMS for an amendment. Knowing that we can’t say ‘no’ that’s why we didn’t set it lower.”

–Program administrator

Because North Dakota cannot set geographical limits or impose caps under a 1915(i) state plan option, eligibility requirements are the state’s only tool for managing enrollment numbers to ensure that the program remains within budget. Initially, program administrators were concerned that the requirements were set narrow enough to ensure that total enrollment, and the resulting total cost, would not exceed budget. Therefore, state officials chose to require that beneficiaries receive a WHODAS score of at least 50 out of a possible 100 points to qualify for 1915(i) services. Based on available information, officials estimated that using a WHODAS score of 50 as the cut-off would allow 11,000 beneficiaries to receive services. However, as of August 18, 2021, only 18 beneficiaries had been found eligible for the program. As a result, state officials became concerned that they would not ultimately enroll 11,000 beneficiaries. In response to stakeholder feedback, they will soon submit a request to CMS to amend the 1915(i) SPA to lower the required WHODAS score to 25. By using the WHODAS to assess functional need, the state can reduce eligibility requirements (and allow more beneficiaries to enroll) by changing the required score without needing to change other aspects of the eligibility process.

About the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)

The WHODAS 2.0 is an assessment instrument which can be administered in about 20 minutes and examines health and disability in six domains: cognition, mobility, self-care, getting along, life activities, and participation. According to the World Health Organization (WHO), the instrument has been found to give consistent results across cultures and for people with different health conditions. Its results are also consistent with other measures of disability/health status and clinician ratings. North Dakota uses the 36-question version of the instrument and a scoring method that produces a score of 0-100 with 0 indicating no disability (i.e., functional impairment) and 100 indicating full disability. The WHO’s studies found that about five percent of the general population would score 50 or more points on the WHODAS; about 15 percent would score 25 or more points. North Dakota requires that the WHODAS be administered by a trained, independent agent and has produced training to supplement that in the WHODAS manual.

Source: World Health Organization. Measuring Health and Disability: Manual for WHO Disability Assessment Schedule (WHODAS 2.0). 2010. https://www.who.int/publications/i/item/measuring-health-and-disability-manual-for-who-disability-assessment-schedule-(-whodas-2.0)

Covered Services Help Members Obtain and Sustain Community Housing

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.

  1. 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.
    1. Pre-tenancy supports help individuals secure housing and include assistance with benefits applications, a housing search, or lease applications.
    2. Tenancy supports help individuals sustain housing and include financial literacy training, education on tenant rights, skills training, and dispute resolution.
  2. 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”

Program Administrator

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.”

Program Administrator

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.

Provider Policies: Designed to Address Rural Workforce Shortages

North Dakota has widespread workforce shortages. Most of its counties contain primary care HPSA’s and almost all of them contain mental health HPSAs. State officials pointed to two policies that were developed to stretch the existing workforce to serve more program members without affecting quality.

“We kept those [provider qualification] requirements as realistic as we could because we know what a provider shortage we face in our state.”

–Program Administrator

Provider qualifications. All 1915(i) services are provided by individuals who bill for services as part of an approved organization. North Dakota’s qualifications for individual direct care providers accommodate the local labor market. These requirements are meant to be inclusive and allow for people without bachelor’s degrees to work if they have other qualifications. For example, to qualify as an individual provider of housing support services an individual must:

  • Have a high school diploma or GED, and either
    • two years of work experience providing direct client services; or
    • an associate degree in a human service field.
  • Be certified in mental health first aid for youth and/or mental health first aid for adults.

Conflict of interest. Federal regulations do not allow care coordination providers to also deliver other services in a person’s POC, unless that provider is the only one available to deliver the service (42 CFR §441.730). Because all but five of North Dakota’s counties are designated mental health HPSAs, CMS has approved North Dakota’s conflict of interest policy which allows providers, including housing providers, that have implemented specific conflict of interest policies to provide both care coordination and other services to 1915(i) members who live in mental health HPSAs. Also, with the approval of the Medicaid agency, providers that are the “only willing and qualified provider with experience and knowledge to serve the individual who shares a common language or cultural background” may provide both care coordination and other services. State officials reported that this was a very important policy for rural areas which have a very limited number of potential care coordination and service providers.

Medicaid officials and housing providers: Overcoming provider participation challenges

“This is an opportunity they [housing providers] did not have before, but it means big internal changes to business models and program”

–Program Administrator

State officials report that housing providers (e.g., group homes, Housing Authorities, and permanent supportive housing providers) saw themselves as housing settings, not providers. The 1915(i) program drew their interest and some have formed a technical assistance group to help them change their business models from grant funding for providing housing to billing Medicaid for providing housing and/or care coordination services. To do that, housing providers need to make the changes needed to be considered a community setting and develop systems for billing Medicaid. Some housing providers worked together to secure the support of a technical assistance person from the Corporation for Supportive Housing and a SAMHSA grant to assist them in that effort. These stakeholders confirm that housing providers need a basic understanding of health care billing before becoming a Medicaid provider and have created technical assistance opportunities and materials to support that need, including establishing a website with resources.

1915(i) program administrators have also developed training and other resources for providers and hold weekly calls where providers can seek assistance. In addition, these administrators are collaborating with those who administer the state’s Money Follows the Person Grant to offer incentive grants to perspective 1915(i) service providers. State officials will be hosting a stakeholder meeting to identify how to best assist providers to enable them to successfully provide 1915(i) services.

Summary

North Dakota designed its 1915(i) program to meet the needs of Medicaid beneficiaries with behavioral health conditions and the challenges of delivering services in rural areas. Policies allowing remote service delivery, allowing care coordination organizations in rural areas to also deliver other services, and establishing provider qualifications that enable organizations to recruit direct care workers despite workforce shortages are all important to enabling members in rural areas to access the services they need to live in their communities. State officials were able to develop and secure federal approval for these policies by consulting stakeholders and then working with federal officials so that all might understand their importance. Of course, there will be more to learn as North Dakota’s experience grows.

Acknowledgments

The National Academy for State Health Policy (NASHP) would like to thank the state officials from North Dakota who contributed to the brief, including reviewing a draft of the document. In addition, we thank representatives of the Corporation for Supportive Housing and the Grand Forks Housing Authority who also provided comments on the draft, as well as Health Resources and Services Administration Project Officer Diba Rab and her colleagues for their feedback and guidance. We also thank the state officials from Montana and the staff of the Montana Healthcare Foundation whose interest in improving the care delivered to Montana Medicaid participants led to the creation of this brief. Finally, the author wishes to thank Hemi Tewarson, Kitty Purington, Jodi Manz, and Luke Pluta-Ehlers of NASHP for their contributions to the paper. This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under co-operative agreement number UD3OA22891, National Organizations of State and Local Officials. The information, content, and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.

North Dakota’s 1915(i) program includes policies that respond to rural challenges

Members living far from their providers: Members may choose to receive some services remotely rather than travel into an office.

Workforce shortages: Direct services providers are not required to have a four-year degree.

Workforce shortages: Organizations that provide care coordination in mental health professional shortage areas may also provide other services.

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