Agenda - 05-10-2011 - 2 - Laserfiche WebLink

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9 as desired. If an individual joins the PIHP and is already established with a provider who is not a member of the network, the PIHPs will make every effort to arrange for the consumer to continue with the same provider if the consumer so desires. In this case, the provider would be required to meet the same qualifications as other providers in the network. In addition, if an enrollee needs a specialized service that is not available through the network, the PIHP will arrange for the service to be provided outside the network if a qualified provider is available. Finally, except in certain situations, enrollees will be given the choice between at least two providers. Exceptions would involve institutional services or highly- specialized services which are usually available through only one facility or agency in the geographic area." 10. Under the waiver will OPC serve all the consumers that are currently being served without a cut in any services? We don't know. In addition to changes that will be created by the waiver, we also anticipate cuts to the rates paid for services. It is hard to say what impact those cuts will have on services. To answer yes to this question would assume that all current treatment plans match the needs of all individuals, which we do not believe has been proven to be the case when records have been audited. In a managed care environment you assess needs at the individual level and create treatment plans that are responsive to those needs within a very formal framework. To answer yes to this question would also assume that the resources currently available would remain so without change. As we are all well aware, North Carolina is facing a serious fiscal shortfall. We are expecting budget reductions at the administrative level and possibly at the service level. Medicaid 8~ Medicare rate reductions are already being rolled out, so the service system will likely face changes unrelated to implementation of the 1915(b) (c) waiver. 11. What will happen to OPC providers? As much as possible, OPC will work to keep our current provider network. One of the rules that is waived under a 1915(b) waiver is freedom of choice. That means waiver sites can have a closed provider network, limiting it to those providers with good outcomes. OPC has been fortunate to have a long-standing relationship with many excellent providers in our community, and that should not change. In fact, PBH has recommended to LMEs interested in becoming waiver sites that current providers be included when the waiver is opened in the LME's community.