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NC Medicaid Transformation

In November 2019, NCDHHS announced that NC Medicaid Transformation efforts will be suspended. NC Medicaid will continue to operate under the current fee-for-service model administered by the department and nothing will change for Medicaid beneficiaries. Behavioral health services will continue to be provided by LME/MCOs. 

Background:

In 2015, the NC General Assembly directed the transition of Medicaid to a privatized managed care structure. For the first time in NC Medicaid history, we will have an integration of behavioral health and physical health reimbursement dollars. In February 2019, NC DHHS announced the four entities who have received contracts to participate as Prepaid Health Plans (PHPs) in Medicaid Managed Care:

  1. AmeriHealth Caritas North Carolina, Inc.
  2. Blue Cross and Blue Shield of North Carolina
  3. UnitedHealthcare of North Carolina, Inc.
  4. WellCare of North Carolina, Inc.

A regional contract for Regions 3 and 5 was awarded to Carolina Complete Health, Inc.

Please note, this procurement is for the Standard Plans, in which 1.6 million Medicaid Managed Care beneficiaries will be enrolled. Tailored Plans, designed for certain populations with more specialized behavioral health needs, will be procured later. Psychiatrists can and should enroll with both the Standard Plans and Tailored Plans.

Standard Plans

The new capitated Standard Plans will cover "mild to moderate" mental illnesses in the Medicaid population, and psychiatrists will be included in the networks to help take care of these patients. These plans are required to accept "any willing provider" who meets quality standards and accepts the Plan reimbursement rate. 

The four statewide Standard Plan PHPs and the regional PLE are now beginning to enroll physicians in these Medicaid networks. 

Under the previous LME/MCO capitated mental health system, multiple Medicaid contracts meant multiple enrollment processes and requirements. NC DHHS is requiring that all of the PHPs and the regional PLE to use the NC DHHS credentialing and enrollment system, a single statewide formulary, and other streamlined processes. The stated goal is to make it easier for all physicians, including psychiatrists, to be Medicaid providers.

For more information on Medicaid Transformation developments, visit the NC DHHS website.

When the statewide transition to managed care begins, patients will begin having their health care paid for by these new Medicaid Standard Plans, many of them will also receive their mental health treatment from professionals in Standard Plan networks. This is why it is extremely important for psychiatrists to consider enrolling in one or more of the Standard Plans.

The company Maximus has been given the enrollment broker contract for NC Medicaid. With the help of Maximus, current Medicaid beneficiaries will enroll in the Standard Plan that best suits their needs. Those who do not enroll will be auto-enrolled.

Transformation of the Current LME/MCO System and Tailored Plans

The current LME/MCO systems will remain in place but will be redesigned as Tailored Plans. Patients with IDD and more serious mental illness and addictions will continue to get their mental health care and enhanced services in the current LME/MCO system. 

Tailored Plans will remain regional and they will be able to close their provider panels as needed. Tailored Plans will cover all the behavioral health services covered by the Standard Plans but will also exclusively cover some enhanced behavioral health services (such as Intensive In-Home, ACT, and Residential SUD treatment).

Resources:

NCDHHS Training Resources

Recorded NC Medicaid Training Courses

FAQs