North Carolina Medicaid Home and Community Based Services Care Cuts

Problem Statement

In 2011, a North Carolina regional managed care organization (which contracts with the state to provide services for programs in Medicaid) called Piedmont Behavioral Health (PBH) sent out alarming notices to people with intellectual and developmental disabilities (IDD) in the home and community based services (HCBS) waiver program of Medicaid. The notices stated that individuals’ HCBS waiver services would soon need to fit within a budget determined by their Supports Intensity Scale (SIS) score. The SIS is an assessment tool generally used for people with IDD, but this announcement was specific to PBH. The new budget would reduce services for many people, but they were told they could not appeal it. The change also occurred in the middle of the plan year, whereas services usually only changed once a year if needs remained the same.

Advocates and beneficiaries filed a class action lawsuit challenging the lack of due process around the use of the SIS. The due process issues were that the SIS budget summary mailed to participants did not include explanations of the scoring system, the meaning of the score, or the score’s effect on services. Another due process issue was that people were unable to appeal their budget assignment. The case also challenged the lack of availability of the exceptions process, called “intensive review.”

The class action was certified and a preliminary injunction was granted in L.S. by and through Ron S. v. Delia. The defendant, PBH, appealed and the decision was upheld in K.C. ex rel. Africa H. v. Shipman, 716 F.3d 107 (4th Cir. 2013). The case was subsequently settled under the title L.S. et al. v. Wos et al.

After the decision in L.S., North Carolina’s Department of Health and Human Services (DHHS) began using the SIS statewide. In the state court case Biggs v. Cohen, plaintiffs identified various ways by which the use of the SIS in North Carolina violated the L.S. settlement agreement. North Carolina DHHS subsequently issued guidance for the regional managed care organizations on how the SIS should and should not be used, and stated that an exceptions process must be available.

Status of Issue

The case is settled, and includes guidance saying the SIS cannot be the sole method used for determining someone’s support needs.

Links to More Information

LS v. Wos Instruction from NC DHHS regarding use of the Supports Intensity Score

L.S. v. Delia decision

NHeLP press release after 4th circuit decision