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
- North Carolina Division of Health Benefits Medicaid Transformation 1115 Waiver
- North Carolina Division of Health Benefits Medicaid Transformation Behavioral Health & I/DD Tailored Plan Design [policy papers and webinars to date]
- North Carolina Division of Health Benefits Medicaid Transformation Requests for Proposals
- North Carolina Division of Health Benefits Medicaid Transformation Policy Papers
- NC Medicaid Clinical Coverage Polices
- NC Medicaid Fee-for-Service Fee Schedules
- Session Law 2015-245 AN ACT TO TRANSFORM AND REORGANIZE NORTH CAROLINA’S MEDICAID AND NC HEALTH CHOICE PROGRAMS
- Session Law 2016-121 AN ACT TO REQUIRE FURTHER REPORTING FROM THE DEPARTMENT OF HEALTH AND HUMAN SERVICES RELATED TO TRANSFORMATION OF THE MEDICAID AND NC HEALTH CHOICE PROGRAMS AND TO MODIFY CERTAIN PROVISIONS OF THE MEDICAID TRANSFORMATION LEGISLATION
- Session Law 2017-186 AN ACT TO CONSOLIDATE THE DIVISION OF ADULT CORRECTION AND THE DIVISION OF JUVENILE JUSTICE INTO A SINGLE DIVISION WITHIN THE DEPARTMENT OF PUBLIC SAFETY, AS RECOMMENDED BY THE JOINT LEGISLATIVE OVERSIGHT COMMITTEE ON JUSTICE AND PUBLIC SAFETY AND TO EXEMPT THE FABRICATION OF EYEGLASSES FROM CAPITATED PREPAID HEALTH PLAN CONTRACTS UNDER MEDICAID TRANSFORMATION
- Session Law 2018-48 AN ACT TO MODIFY THE MEDICAID TRANSFORMATION LEGISLATION
- Session Law 2018-49 AN ACT TO REQUIRE MEDICAID PREPAID HEALTH PLANS TO OBTAIN A LICENSE FROM THE DEPARTMENT OF INSURANCE AND TO MAKE OTHER CHANGES PERTAINING TO MEDICAID TRANSFORMATION AND THE DEPARTMENT OF INSURANCE
- Session Law 2019-81 AN ACT TO MODIFY THE LAWS PERTAINING TO MEDICAID AND NC HEALTH CHOICE AS NEEDED FOR THE IMPLEMENTATION OF MEDICAID TRANSFORMATION
- Centers for Medicare and Medicaid Services 1115 waiver information
- Centers for Medicare and Medicaid Services Code of Federal Regulations [See 42 C.F.R. Part 438 for Medicaid Managed Care specifically]
- Title XIX of the Social Security Act [Medicaid Program]
- Title XXI of the Social Security Act [Children’s Health Insurance Program]