North Carolina Medicaid Transformation

North Carolina Medicaid Transformation Series

Beginning in June 2019, North Carolina will go through a Medicaid ‘Transformation’ or in its formal name, Medicaid Managed Care. Within this transition, the normal fee-for-service model will change to a managed care model. According to NCDHHS, this new plan will:

  • Deliver whole-person care through coordinated physical health, behavioral health, intellectual/developmental disability and pharmacy products and care models
  • Address the full set of factors that impact health, uniting communities and health care systems
  • Perform localized care management at the site of care, in the home or community
  • Maintain broad provider participation by mitigating provider administrative burden

The transformation process will have multiple phases and will roll-out for different regions at different times. See the timeline and map below to view your region and roll-out phase.

nc medicaid timeline
nc medicaid regions map

Provider Transition to NC Medicaid Managed Care


medicaid Managed Care plan – Key takeaways [faq]

Beneficiary Information

The majority of Medicaid and NC Health Choice beneficiaries will now receive Medicaid through Prepaid Health Plans (PHPs).

Types of Plans Offered

There will be two types of products:

  • Standard Plans for most beneficiaries
  • Tailored Plans for high-need populations

Plan Selection

DHHS will provide choice counseling, enrollment assistance and education to beneficiaries to help them select a plan. If beneficiaries do not select a plan manually, they will be auto-enrolled per DHHS’s enrollment standards.

PHP & Provider-Led Entity Options

As it stands right now, there are only 4 statewide contracts and 1 provider-led entity in place, however DHHS is working on partnering with more PHPs in the future.

Four Statewide PHP Contracts:

  • AmeriHealth Caritas North Carolina, Inc.
  • Blue Cross and Blue Shield of North Carolina, Inc.
  • UnitedHealthcare of North Carolina, Inc.
  • WellCare of North Carolina, Inc.

One Regional Provider Led Entity

  • Carolina Complete Health, Inc. (Regions 3 and 5)

Provider Enrollment and Credentialing

The old way of applying and verifying  with NC Medicaid will be no more. Instead of contracting directly with the state, NC Medicaid providers will contract and be reimbursed by PHPs. Providers will now follow a PHP process that includes the following steps:

Step 1: Provider contacts PHP or submits application per PHP guidelines

Step 2: PHP PNPC reviews & approves/denies application

Step 3: Once approved, provider and PHP negotiates contract

Step 4: Once contract is secured, provider is enrolled in Medicaid

Provider Payment

Payment for providers will now have an In-Network Payment rate floor and Out-of-Network Payment rate floor, although there is no information on what the general rate-floor looks like from each PHP.

Payment to in-network hospitals, physicians, and physician extenders  works a bit different as payments must be no less than 100% of the Medicaid fee-for-service rate, unless otherwise specified and PHPs must maintain the contract rate for the first 3 contract years.

Claim Submission

Going through NC Tracks to submit and track your readmittance will unfortunately not move forward in this new Managed Care Plan.  Going forward, these claims will be submitted to the PHP in which that member was enrolled where they would process those claims and make reimbursements to you for providing those services.

To get the full scoop on the Provider Transition to NC Medicaid Managed Care, be sure to check out the direct resources from NCDHHS below!



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Resources & Credits:
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NC Medicaid

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