Medicaid Transformation

Medicaid Transformation

In 2015, the North Carolina General Assembly enacted legislation to authorize a transition to: Medicaid managed care statewide and regional contracts; the creation of the Division of Health Benefits to administer the State Medicaid and NC Health Choice (CHIP) programs; and the dissolution of the Division of Medical Assistance.  The General Assembly has amended the 2015 legislation in each subsequent legislative session to further clarify and appropriate funding for the incremental transition.  Clarifications have included Health Plan licensure and solvency requirements in collaboration with the NC Department of Insurance; Health Plan contract provisions, including Medical Loss Ratios and State authority to implement withholds for value-based payment; managed care enrollment mandatory and exempt beneficiary populations; and covered service carve-outs.  Legislation has also yielded a road map for two distinct types of managed care plans:  Standard Benefit Plans for the majority of Medicaid and NC Health Choice beneficiaries, and Tailored Plans for high-risk, high need populations including but not limited to I/DD, TBI, SMI, and SED.  However, both Plan types must contract to deliver integrated, whole-person care that coordinates physical and behavioral health services with pharmacy via care management.

Medicaid Transformation has necessitated NC DHHS 1115 waiver applications to the Centers for Medicare and Medicaid Services (CMS); State Plan Amendments; and Requests for Information and Requests for Proposals for numerous Health Plan and tangential vendor contracts for Transformation planning and implementation.  DHHS and the Division of Health Benefits have published concept papers, referred to as policy papers, and sponsored statewide webinars to keep stakeholders informed.  CMS approved North Carolina’s 1115 Demonstration Waiver in October of 2018.  The Waiver is effective January 1, 2019 through October 31, 2024. NC DHHS is scheduled to begin the first phase of Standard Plan implementation on November 1, 2019 in two of six regions (2 and 4), and in the remaining four regions (1, 3, 5, and 6) in February of 2020.  Tailored Plans are scheduled to begin in 2021.

North Carolina Providers Council members are committed MH/DD/SAS providers and stakeholders in this Transformation. Members currently serve Medicaid beneficiaries and uninsured individuals under a service delivery system of managed behavioral health care through closed network contracts with seven regional, Local Management Entity / Managed Care Organizations (LME/MCOs) that serve all 100 NC counties.  Members will continue to serve beneficiaries through LME/MCO contracts, but they may also contract with Standard Plan networks to serve beneficiaries with mild-to-moderate MH/SAS service needs.  The North Carolina Providers Council therefore closely monitors all legislation and other documentation related to Medicaid Transformation and communicates regularly with members.  The Providers Council also maintains a collaborative relationship with the LME/MCOs, Health Plans, and State Officials, and sponsors opportunities for members to have a dialogue with representatives during standing Committee meetings, at membership leadership forums, and at the annual conference.

Listed below are “Quick Links” for accessing NC DHHS and Division of Health Benefits documentation related to Medicaid Transformation.  This page will be updated on an ongoing basis as the State publishes additional information.

North Carolina Medicaid Transformation Quick Links

State Resources

Federal Resources