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Provider Alert: 1915(b)(3) transition to 1915(i)

Issued: June 28, 2024

On June 26, 2024, Partners Health Management received notice from the NC Department of Health and Human Services (NCDHHS) with guidance on transitioning NC Medicaid Direct and Tailored Plan members from 1915(b)(3) services to 1915(i) services. This alert provides details on the transition pathways from 1915(b)3) to 1915(i) based on the member’s eligibility as of July 1, 2024.

What’s happening?

NCDHHS provided direction on June 26, 2024, regarding transitioning NC Medicaid Direct and Tailored Plan members from 1915(b)(3) services to 1915(i) services. The pathways for transition are laid out below based on the member’s eligibility effective July 1, 2024.

NC Medicaid Direct Benefit Plan:

NCDHHS received approval from the Centers for Medicare and Medicaid Services (CMS) to renew the 1915(b) Waiver, under which members receiving 1915(b)(3) services will be transitioned to 1915(i). 1915(b)(3) services under NC Medicaid Direct will be phased out no later than December 31, 2024.

To ensure members receiving medically necessary Home and Community Based Services (HCBS) experience minimal disruption, and to comply with the CMS requirements, NC Medicaid Direct members receiving 1915(b)(3) services:

  • Must be assessed for 1915(i)
  • Have a Person-centered Care Plan/ISP developed for 1915(i)
  • Complete the transition from 1915(b)(3) to 1915(i) by no later than November 30, 2024.

Tailored Plan Benefit Plan:

NCDHHS intends to exercise the presumptive payment option permitted under Section 1915(i) of the Social Security Act to enable certain Tailored Plan members to receive 1915(i) services upon Tailored Plan launch on July 1, 2024.

  • Carelon, on behalf of NCDHHS, will send out letters to Tailored Plan members who NCDHHS has determined may be eligible for 1915(i) services to grant up to 60 calendar days (July 1-Aug. 30, 2024) of presumptive eligibility for 1915(i) services.
  • NCDHHS will identify which members qualify for presumptive eligibility, which may include:
    • Tailored Plan members (as of July 1, 2024) who were receiving 1915(b)(3) services under NC Medicaid Direct who have not had a 1915(i) Independent Assessment completed prior to June 30, 2024.
    • Tailored Plan members who were previously eligible (under NC Medicaid Direct) for 1915(i) and require a reassessment for 1915(i) services.
    • Presumptive eligibility cannot be given to members above 150% Federal Poverty Level (FPL). More information below.
  • Members may continue to receive Home and Community Based Services (HBCS) under 1915(i) and pursuant to an approved Person-Centered Care Plan (care plan/individual support plan (ISP).
  • For any presumptively eligible members who do not have an active Person-Centered Care Plan or ISP when they are granted presumptive eligibility (effective July 1, 2024), a Tailored Care Manager or Partners Care Coordinator will ensure the member has a documented Interim Care Plan to identify the 1915(i) services accessible to the member during the period of presumptive eligibility.
    • Interim Care Plans cannot include new
    • Interim Care Plans are to support continuity of care for services authorized and deemed medically necessary under 1915(b)(3) prior to July 1, 2024.
  • 1915(i) presumptive eligibility will end on the earlier of 1915(i) eligibility determination (approval or denial for the member) or 60 days (August 30, 2024), whichever comes first.

During the period of presumptive eligibility, the following steps must be completed by the Tailored Care Manager or Partners Care Coordinator for the member to continue eligibility for 1915(i) services following conclusion of the presumptive eligibility period:

  1. Complete the 1915(i) assessment required under 42 CFR 441.720 within the 60-day period.
    1. Tailored Care Manager or Partners Care Coordinator should aim to complete all 1915(i) independent assessments by July 31, 2024, to allow for the 1915(i) independent evaluation and determination eligibility for each member as required by 42 CFR 441.715.
  2. Complete the Person-Centered Care Plan/ISP for presumptively eligible members so that if determined eligible by independent evaluation, the member can continue to access 1915(i) services without disruption.

Tailored Plan Members above the 150% Federal Poverty Level (FPL):

  • Presumptive eligibility cannot be given to members above 150% FPL.
  • Any member who has not been assessed in the last 12 months must be reassessed prior to independent evaluation and determination of 1915(i) eligibility.
  • NCDHHS will provide Partners with a list of members with income over 150% FPL and whose assessment is more than 12 months old prior to July 1, 2024. This will allow the Tailored Care Manager or Partners Care Coordinator to coordinate with providers to complete the member’s reassessment and develop the Person-Centered Care Plan/ISP.
  • Members already receiving 1915(b)(3) services can continue to receive 1915(b)(3) until the 1915(i) Care Plan/ISP is approved and services are authorized.
    • If these members are receiving 1915(b)(3) services, they must be transitioned to 1915(i) or another appropriate service or otherwise stop 1915(b)(3) services no later than Sept. 30, 2024.

What is happening to the member’s 1915(b)(3) or 1915(i) authorization?

Medicaid Direct Benefit Plan:

  • Current active 1915(b)(3) authorizations – no changes have been made at this time.
  • Current active 1915(i) authorizations – no changes have been made.
  • 1915(b)(3) services under the NC Medicaid Direct Benefit Plan will be phased out by December 31, 2024. Providers will not be able to use the 1915(b)(3) codes after that date.
  • Members need to complete transition to 1915(i) by November 30, 2024, or to another appropriate service prior to December 31, 2024.
  • The expectation is that the 1915(i) Independent Assessment will be completed before any 1915(b)(3) service is authorized for initial or concurrent review for NC Medicaid Direct members.

Tailored Plan Benefit Plan:

  • For members authorized for a 1915(i) service(s) with an end date of July 1, 2024, or later under NC Medicaid Direct who are Tailored Plan eligible on July 1, 2024 – Partners Utilization Management has split the authorization(s) for the July 1, 2024, change. The current authorization(s) will be end-dated June 30, 2024. This authorization number will not change. A new authorization will be created with Tailored Plan Applied Eligibility starting July 1, 2024, through the original end date. The new authorization will have a new authorization number. Both authorizations are visible in ProAuth.
  • For members deemed by NCDHHS to be presumptively eligible:
    • UM will transition the 1915(b)(3) authorization to the appropriate 1915(i) service with prorated units (as applicable) and an end date of Aug. 30, 2024. A Care Plan/ISP or Interim Care Plan (must specify service and frequency) is required.
  • For members who have had the 1915(i) Independent Assessment and evaluation completed but do not have a 1915(i) service authorization in place:
    • The Tailored Care Manager or a Partners Care Coordinator will need to submit a Care Plan/ISP with a service authorization request effective July 1, 2024, or
    • Submit an Interim Care Plan with a service authorization request effective July 1, 2024, through Aug. 30, 2024. The Tailored Care Manager or a Partners Care Coordinator will develop the full plan and submit it for concurrent authorization before Aug. 30, 2024.
  • No new or initial authorizations for 1915(b)(3) services will be issued for Tailored Plan members as of July 1, 2024.

For Tailored Plan Members above 150% Federal Poverty Levels:

  • 1915(b)(3) services are not otherwise available under the Tailored Plan, so only those members specified on the lists provided by NCDHHS can receive authorized 1915(b)(3) services. Partners Utilization Management will create these 1915(b)(3) authorizations based off the list provided by NCDHHS.
    • 1915(b)(3) providers should continue to submit concurrent authorization requests until the member transitions to 1915(i) or another appropriate service.
  • 1915(b)(3) services authorized under the outlined Tailored Plan special criteria above will be ended (as applicable):
    • 30, 2024, for Tailored Plan Member above the 150% FPL.
    • Or upon transition to 1915(i) or another appropriate service

What do Providers need to do?

  • Providers who previously had 1915(b)(3) services in their NC Medicaid Direct contract will have those services added to their Tailored Plan contract.
  • No action is required regarding the provider’s Tailored Plan contract.
  • No additional 1915(b)(3) funding will be added to the provider contract for Tailored Plan or NC Medicaid Direct.
  • Providers should work with the assigned Tailored Care Manager or Partners Care Coordinator on the tasks required to transition all members from 1915(b)(3) to 1915(i).

What do Members need to do?

  • Members should work with their Tailored Care Manager or Partners Care Coordinator to complete the tasks required to transition from 1915(b)(3) to 1915(i).
  • If the member’s 1915(i) independent evaluation is denied by NCDHHS, appeal rights are issued by NCDHHS vendor, Carelon.

What do Tailored Care Managers or Partners Care Coordinators need to do?

Tailored Care Managers or Partners Care Coordinators need to complete the required tasks to transition members from 1915(b)(3) to 1915(i) services as soon as possible (see deadlines outlined above per the Benefit Plan). These tasks include:

  • Completion of the 1915(i) Independent Assessment
  • Submission of the 1915(i) Independent Assessment to the NCDHHS vendor, Carelon
  • Develop the Care Plan or Individual Support Plan (ISP)
  • Submit prior authorization and Care Plan/ISP to Partners Utilization Management for review
  • Follow up to ensure services begin within 45 days of authorization

Who do I contact if I have questions?

Updated: