NC Medicaid Transformation

NC Medicaid Managed Care Transformation efforts have been restarted. Standard Plans are scheduled to go live July 1, 2021, while Behavioral Health I/DD Tailored Plans are scheduled to launch July 1, 2022. Until that time, NC Medicaid will continue to operate under the current model.

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.

Quicklinks to Plan Resources:

NC DHHS | AmeriHealth Caritas | Carolina Complete Health | Healthy Blue | United Healthcare | WellCare

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 enrolling 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.

As with any major change, there are sure to be things that do not go according to plan, and the NC Medical Society (NCMS) and partners such as NCPA, have developed a process we hope will help our members deal with this momentous shift in how services will be delivered to patients covered by Medicaid. The NCMS, with support by a number of specialty groups including NCPA, has created a special form where you can log any issues you have with one of the Managed Care Plans . The purpose is to aggregate common complaints so we can communicate with the state and our contacts at each health plan what many members are experiencing. If issues occur, please reach out to the plan first to share your experience. If the issue persists, then you can complete the Medicaid Transformation Issues form. Thanks to the NCMS for their work leading this effort.

When the statewide transition to managed care begins on July 1, 2021, 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.

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Resources:

NC DHHS

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

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AmeriHealth Caritas

Provider Support Number:  888-738-0004

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Carolina Complete Health

Provider Support Number:  833-552-3876

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Healthy Blue

Provider Support: 844-594-5072

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United Healthcare

Provider Support: 800-638-3302

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WellCare

Provider Support:  866-799-5318

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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

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