North Carolina is switching to managed care in its Medicaid system, and patients and providers will have to make some choices.
NC Families United wishes to thank Ben Steelman – Star News Oct 18,2018 for excerpts of information
Starting on November 1, 2019 a new MEDICAID System will be introduced to North Carolina’s Medicaid coverage in 2019. NC Families United has been told the switch over will be seamless and families will barely notice the difference, but families will have to make a few choices and also understand the differences between the Standard Plans for physical/mental health (routine visits, quick treatment needs) and the Tailored Plans (critical long term needs, more intensity and 3 levels of services for children and youth).
So what is it? Basically, the state is switching its Medicaid NC Health Choice programs from fee-for-service to a managed care delivery system. Medicaid claims will be handled by “prepaid health plans,” or PHPs, which will enroll patients and will pay doctors, physician assistants and other health care professionals. PHPs would be private entities working on contracts with state government and individual providers. Officials hope to roll out the plan in November 2019. A few hoops must be jumped, though. The federal government — specifically, the U.S. Centers for Medicare and Medicaid Services — must approve North Carolina’s proposals under what’s known as a Section 1115 waiver. “We’re still waiting,” Ludlam said, “but we feel like we’re very, very close.”
Another milestone passed on Oct. 12, the deadline for organizations to file with the state to become PHPs. Officials are reviewing these proposals now, Ludlam said. From these, the state is expected to award four statewide contracts for PHPs, according to Mandy K. Cohen, state DHHS secretary.
Most families will be “auto-assigned” to one PHP or another. They may, however, review the plans and choose one which fits their needs, Ludlam said. If their preferred doctor or provider is not in their assigned plan, they will have the option to switch to another within 90 days of the program’s start in November 2019. NC Families United will be available to families to help navigate through the possible confusion. We at NC Families United are doing everything to get our staff trained to help parents understand.
The same health services will be covered under managed care, including doctor’s and hospital visits, prescription drugs, childbirth and long-term care. Ludlam says he hopes managed care will give patients more options in fields such as disability care and behavioral health care, which can include treatment for drug addiction. North Carolina will also adopt a single pharmacy formulary for the entire state.
State government won’t be entirely out of the picture, though. DHHS will oversee the overall Medicaid program and the PHPs, working to ensure adequate care networks and timely payments. It will also operate a credentialing system for providers in the Medicaid system.
A few Medicaid services, such as family planning, will remain under the old fee-for-service system. However, the state estimates that more than 90 percent of Medicaid recipients will be under managed care plans by the end of 2019.
NC Families United will be watching events closely and meeting with the DHHS MEDICAID when input is required. Stay Tuned
Gail M. Cormier
North Carolina Families United