Update, March 2021:
If you are looking for more recent information about Medicaid Transformation, please visit this post.
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Editor’s note: This is an update to information posted Sept. 11, 2019. The managed-care rollout has been suspended by DHHS at this time.
As a result of the budget impasse, NC DHHS has suspended the roll out and implementation of Medicaid managed care, often referred to as Medicaid transformation. This will not go live as previously planned on February 1, 2020. This means that those who were identified as eligible to choose new plans under transformation do not need to take any action at this time. Medicaid services will continue as they are now. For the latest updates, continue to review DHHS’s webpage on transformation. Also see the Medicaid Q&A.
As we learn of major updates from DHHS based on the budget or other factors, we will update this post. We would like to acknowledge the work and effort of DHHS staff, health plans, providers, associations, families, individuals with disabilities, and others to move toward a vision of a healthier NC.
From DHHS:
With managed care suspended, NC Medicaid will continue to operate under the current fee-for-service model administered by the department. Nothing will change for Medicaid beneficiaries; they will get health services as they do today. Behavioral health services will continue to be provided by Local Management Entities/Managed Care Organizations. All health providers enrolled in Medicaid are still part of the program and will continue to bill the state through NCTracks.
Open enrollment had begun for part of the state in July and launched statewide in October. The North Carolina Enrollment Broker Call Center (833-870-5500) will stay open through Dec. 13, 2019 to answer questions but will no longer enroll beneficiaries in a health plan. Beneficiaries can continue to contact the Medicaid Contact Center (888-245-0179). Notices will be sent to beneficiaries informing them to continue accessing health services as they do now, rather than through new health plans.
The suspension of work and the wind-down process will begin tomorrow. Once suspended, managed care cannot easily or quickly be restarted. The department will not decide on a new go-live date until it has program authority within a budget that protects the health and safety of North Carolinians and supports the department’s ability to provide critical oversight and accountability of managed care.
Background: In 2015, the NC General Assembly enacted legislation directing DHHS to transition Medicaid and NC Health Choice from fee-for-service to managed care. Under managed care, the state contracts with insurance companies, which are paid a predetermined set rate per person to provide all services. The department was on track to go live Feb. 1, 2020. New funding and program authority was required from the General Assembly to meet this timeline.
The following article contains information effective before the suspension of Medicaid Managed Care.
The NC Department of Health and Human Services is in the process of implementing Medicaid transformation in North Carolina. The vision of DHHS is “Improving the health and well-being of North Carolinians through an innovative, whole-person centered and well-coordinated system of care that addresses both medical and non-medical drivers of health.” DHHS plans to implement these changes in coming years after developing policy based on feedback from a wide variety of stakeholders since 2015.
For more information about how and why this came about, please visit our older blog articles outlining the proposal and development of the plans:
Starting in early 2020, Medicaid recipients in North Carolina will have their health services managed by private insurance companies as NC Medicaid switches from a public fee-for-service system to a private managed-care model. Instead of the state of North Carolina managing the program directly, insurance companies will be paid a per-member, per-month fee to work with people on Medicaid to manage their health services, similar to how health care works for people with private health-care coverage. Our state’s plan is unique in that it plans to incorporate elements of non-medical drivers of health, such as housing, transportation, food insecurity, etc. as well.
Standard vs. Tailored Plans
During this transformation of how health services are managed, Medicaid will integrate physical health care with behavioral health care so that people will, hopefully, be healthier and have an easier time getting services regardless of the type of healthcare needs they have. This involves services and supports for physical, pharmaceutical, behavioral, and social needs. There will be two separate identified plans to provide this: Standard and Tailored.
Standard Plans will be available for those with mild to moderate behavioral health or substance use needs. Tailored Plans will be for those with more complex or lifelong needs, for example, people on the Innovations waiver. People will be enrolled in a Standard or Tailored Plan based on various eligibility factors. Four statewide Standard Plans will be offered by AmeriHealth Caritas NC, WellCare, Healthy Blue NC, and United Healthcare NC. A regional provider-led entity, Carolina Complete Care, will also operate a Standard Plan in one area. People who move to Standard Plans will choose one of these to manage their health services.
For detailed information on eligibility determination for plans, see the policy design paper.
When Is This Happening?
Note: As of Nov. 19, 2019, DHHS has suspended the implementation of managed care.
This switch to integrated private managed care will happen in two phases: the Standard Plan rollout, and Tailored plan rollout.
Most people with autism will continue to have their health services managed as they are now through NC Medicaid (also known as Medicaid Direct). Their behavioral health and IDD services will continue to be managed by LME/MCOs at this time. Based on diagnoses and services as referenced in the above eligibility link, most people with autism will not see changes to the management of their health benefits until the Tailored Plans roll out.
For general information on Medicaid as a health insurer and how to apply, see DHHS’s website.
For more information on accessing local behavioral health or IDD services, see the LME/MCO county map.
People began receiving enrollment packets from Medicaid this summer to explain the change, and if they are eligible, give them the choice to begin selecting a new health-care insurance company (Standard Plan) and primary care provider (PCP). Those who are part of the Standard Plan rollout and have not selected a company will be automatically assigned based on where they live, their eligibility, where they seek their health care, and where other members of their household are assigned.
What Do Individuals with Autism or Their Families Need to Do?
Note: No action is required based on DHHS’s suspension of transformation roll out on Nov. 19, 2019.
If Medicaid is your health insurer, you or your child will have the option of enrolling in a Standard or Tailored Plan based on eligibility criteria. People who have Medicaid as their health insurer and are using Medicaid b3, state funded (IPRS), or other Medicaid services (e.g. ABA through Medicaid, Research-Based Behavioral Health Treatment) and are NOT on the Innovations waiver, will get a letter indicating options to enroll in a Standard Plan or remain in the Tailored Plan based on eligibility factors. The Tailored Plan will be operated by LME/MCOs, and services should remain unchanged until 2021. You will continue to receive your primary health-care services through Medicaid as you do now if you do not enroll in a Standard Plan. You should carefully weigh your options and choices as most support services for people with ASD (like b3 respite, IPRS Developmental Therapy, Innovations waiver) are not available in Standard Plans. At this time, most services for people with Autism Spectrum Disorder remain in the Tailored Plan (LME/MCOs).
As always, it is important for people to get on the waitlist and ensure their information is up to date with DSS and LME/MCOs for services. Individuals who are on the Innovations waiver, CAP/DA, CAP Child or dually enrolled with Medicaid and Medicare will not move into standard plans. There are other exceptions to eligibility criteria. For children receiving Research Based Behavioral Health Treatment, those services should be available in both Tailored and Standard Plans in addition to regular health services.
If you are eligible for the Standard Plan, more information and contacts for who can help you choose a plan and provider can be found on the Enrollment Broker’s website, found here. It’s important to know that if you do choose a Standard Plan, and your needs change for services not available in the Standard Plan, you can seek to move back to a Tailored Plan. We will publish more information on this in the future as details are worked out. It is also important to note that individuals who are on the waitlist for Innovations waiver services will also be automatically enrolled into the Tailored Plan, unless they choose to opt out and into a Standard Plan. They can maintain their place on the Innovations waiver waitlist if they are eligible to and choose to enroll in a Standard Plan.
Here are the behavioral health and IDD services available in each plan from DHHS:
Covered by Both Standard Plans and Behavioral Health IDD Tailored Plans
State Plan Behavioral Health and IDD Services
- Inpatient behavioral health services
- Outpatient behavioral health emergency room services
- Outpatient behavioral health services provided by direct enrolled providers
- Partial hospitalization
- Mobile crisis management
- Facility-based crisis services for children and adolescents
- Professional treatment services in facility-based crisis program peer supports
- Outpatient opioid treatment
- Ambulatory detoxification
- Substance abuse comprehensive outpatient treatment program (SACOT)
- Substance abuse intensive outpatient program (SAIOP) pending legislative change
- Clinically managed residential withdrawal (social setting detox)
- Research-based intensive behavioral health treatment
- Diagnostic assessment
- EPSDT
- Non-hospital medical detoxification
- Medically supervised or ADATC detoxification crisis stabilization
Covered Exclusively by Behavioral Health IDD Tailored Plans (or LME-MCOs Prior To Launch)
State Plan Behavioral Health and IDD Services
- Residential treatment facility services for children and adolescents
- Child and adolescent day treatment services
- Intensive in-home services
- Multi-systemic therapy services
- Psychiatric residential treatment facilities
- Assertive community treatment
- Community support team
- Psychosocial rehabilitation
- Substance abuse non-medical community residential treatment
- Substance abuse medically monitored residential treatment
- Clinically managed low-intensity residential treatment services
- Clinically managed population-specific high-intensity residential programs
- Intermediate care facilities for individuals with intellectual disabilities (ICF/IID)
Waiver Services
- Innovations waiver services
- TBI waiver services
- 1915(b)(3) services
State-Funded BH and I/DD Services
State-Funded TBI Services
What Benefits Are There to Transformation?
The benefits of transformation include having choice, access to care management, and coordinated approaches to physical, behavioral, and social needs. People should be able to compare the benefits of each plan and choose the one that best supports themselves and their family. Both Standard and Tailored (2021) Plans will provide access to care management, which should serve as a central hub to all needs in the Medicaid system. Care management, as defined in transformation, will include “the involvement of a multidisciplinary care team and the development of a written care plan.”
As mentioned at the beginning of this article, one of the goals of transformation is to integrate physical and behavioral health care. Plans must work to address not just direct health care, but also non-medical drivers of health, such as nutrition and food insecurity, obesity, lack of exercise, smoking, access to transportation, and employment. This will benefit all North Carolinians, including the autism community.
Where Can I Learn More?
DHHS has a wealth of information online at www.ncdhhs.gov/assistance/medicaid-transformation. Find FAQ documents here.
You may also contact us at 800-442-2762 (press 2) for additional information. We know this is a complex issue to navigate.
This is the largest change to North Carolina’s Medicaid system in 40 years. We applaud the hard work and vision of DHHS to move North Carolina to a healthier population overall. We will continue to inform, advocate, and translate what this means for people with autism in the future.
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