Several issues remain controversial and under discussion, especially around the role of the LME. The reform legislation sought to strike a balance between state and local control by requiring the state to establish clear and consistent expectations and standards. Local communities were to determine how they would meet those standards and expectations through the development of a local plan that would be implemented and managed through the LME.

Through the plan, the state has put forward its expectations and standards. Although some refinement and clarification will probably be needed, it is the most comprehensive and detailed effort ever put forward by the state. The result is a system that is more state driven. The state has established a state access and referral line, is requiring state utilization management of all services, is proceeding with billing by providers directly to the state, and has tapped the state Division of Facility Services to provide statewide monitoring and licensing activities. When combined with the criteria limiting the provision of services by LMEs, some question what the role of the LME will be. More work and discussion needs to occur to clarify this.

There also is some controversy around the question of service provision. The intent of the reform legislation was to encourage the development of networks of private and non-profit providers. The idea was to put LMEs in charge of developing and managing these networks. The legislation does not prohibit LMEs from offering services but requires the Secretary to approve LMEs that want to offer services. This was done to limit the conflict of interest that exists when an LME offers services while also having the responsibility of developing a network of competitors for that same service. The idea was that the Secretary would look to see that the LME had really tried to develop a network of quality providers. There are some concerns, however, that criteria put forward in the local plan document may be too restrictive and some modifications my need to be made. Unfortunately, some individuals are raising alarms with consumers and families by claiming that area programs will have to "shut down all services". Neither the legislation nor the state plan requires programs to shut down all services. It does require that communities look at what services are needed, develop provider networks wherever possible, identify services where sufficient qualified providers are not available or where the LME is uniquely qualified to provide a service. The LME can then apply to the Secretary to provide those services the local plan has identified the LME ought to provide.

The Secretary of DHHS is well aware of the balance that is trying to be struck. She is open to considering giving LMEs UM authority some time in the future, but not now. She is committed to developing a standard for services and management that is applicable across the state and that minimizes paperwork and duplication for providers. She is committed to ensuring a continuum of quality services. It appears that she believes the best way to achieve this, at least in the short run, is for the state to take a more active role.