Melody Couch
J. Dalton
English 111
April 28, 2016
Medicaid Waiver, Best or Mess
Prior to 2012, Medicaid for Behavioral Health was governed by the state of North
Carolina through a contract with High Point (HP) Enterprise to make the payments. The
behavioral health benefits had a cap or limit of visits that each person could use for these
services. An adult, persons over age 21(twenty-one), were only allowed 8 (eight unmanaged
visits, and a person under age 21 was allowed 27 unmanaged visits. Unmanaged visits were
approved by the patients Primary Care Provider (PCP). If a patient needed to be seen for further
therapy treatment, the mental health provider would to fill out an Outpatient Referral Form
(ORF) and submit the needed information for additional visits to ValueOptions. ValueOptions
would then review for medical necessity and approve or deny additional visits. The care was in
the hands of the primary care doctor, the patient and therapist. Not the government. The
government is mandating what services the patients need and how often, instead of the
doctors. Is this a good choice for patients? Any number under 100 type completely out.
Prior to the adaption of the waiver in North Carolina, according to providers, there is a lot
involved about the process that is not told to patients. Such processes include restrictions on
visits, referrals, and a referral restrictions to specialty offices. (Fried, Bruce J; Topping,
Sharon; Morrissey, Joseph P; Ellis, Alan R)
Couch 2
In 2012, the state of NC adapted the Managed Care Waiver 1915(b). This changed the payer
to Local Management Entities (LME’s). The state of NC went from a one payer (HP), to multiple
payer entities across the state. Under the new LME the patient visits decreased for patients
under age 21, from 27 visits to 16 unmanaged. Any number under 100 type completely out.
Each provider had three forms to fill out after the first initial visit and would need to continue
to fill out forms after so many visits. When a provider seen a patient, whether or not Medicaid,
they would allow 50 minutes for face-to-face contact with the client and approximately 10
minutes for them to complete the therapy note.
Medicaid is now a Health Maintenance Organization (HMO). The providers would have to
be credentialed with the LME as well as Medicaid. The LME, in 2012 when the waiver was
