North Carolina Medicaid Transformation: Beneficiary Policies May 16, 2019 - NC.gov
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North Carolina Medicaid Transformation: Beneficiary Policies May 16, 2019
Contents
North Carolina Medicaid Managed Care Transformation
Deep Dive: Beneficiary Policies
More Opportunities for Engagement
Q&A
Appendix
2Medicaid Transformation Vision
“ To improve the health of North Carolinians
through an innovative, whole-person centered,
and well-coordinated system of care
which addresses both medical and
”
non-medical drivers of health.
3Context for Medicaid Transformation
In 2015, the NC General Assembly enacted Session Law 2015-245, directing the
transition of Medicaid and NC Health Choice from predominantly
fee-for-service (FFS) to managed care.
• Since then, the North Carolina Department of Health and Human Services (DHHS)
has collaborated extensively with clinicians, hospitals, beneficiaries, counties,
health plans, elected officials, advocates, and other stakeholders to shape the
program, and is committed to ensuring Medicaid managed care plans:
• 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
4Medicaid Transformation Timeline
Timeline Milestone
October 2018 1115 waiver approved
February 2019 PHP contracts awarded
Enrollment Broker (EB) sends Phase 1
June - July 2019
enrollment packages; open enrollment begins
PHPs contract with providers and meet network
Summer 2019
adequacy
Managed care Standard Plans launch in selected
November 2019
regions; Phase 2 open enrollment
Managed care Standard Plans launch in
February 2020
remaining regions
Behavioral Health and
Tentatively July
Intellectual/Developmental Disability (BH I/DD)
2021
Tailored Plans Launch
5Contents
North Carolina Medicaid Managed Care Transformation
Deep Dive: Beneficiary Policies Beneficiary Eligibility and
Enrollment Process
More Opportunities for Engagement PCP Selection
Beneficiary Supports
Q&A Grievances, Appeals, and
Other Consumer Protections
Appendix Addressing Social Needs
6Beneficiary Eligibility and Enrollment Process
Beneficiary Eligibility for Managed Care
• Most Medicaid beneficiaries (e.g., parents and caretaker adults, children
enrolled in Medicaid and NC Health Choice) will transition to Standard Plans
beginning in November 2019
• Other Medicaid beneficiaries will transition to managed care at a later date or
remain in fee for service
• DHHS will continue to determine Medicaid eligibility for all Medicaid
beneficiaries following managed care implementation
Providers can review their
patient populations to
determine which patients
are, and are not, transferring
to managed care
8Beneficiary Eligibility for Managed Care, cont.
Some Medicaid eligible populations will not transition to managed care
until a later date or at all; others have the option to stay in fee for service
Excluded Populations Delayed until BH I/DD Tailored Plan Launch
Medically needy beneficiaries (i.e., spend down) Qualifying beneficiaries with a:
Beneficiaries with limited Medicaid benefits (e.g., family
Serious mental illness;
planning)
Community Alternatives Program for Disabled Adults Serious emotional disturbance;
(CAP/DA)
Severe substance use disorder;
Community Alternatives Program for Children (CAP/C)
Program of All-Inclusive Care for the Elderly (PACE) Intellectual/developmental disability; or
Traumatic brain injury
Temporarily Excluded for up to 5 years Exempt (Optional Enrollment in MMC)
Beneficiaries with long-term nursing facility stays Members of federally recognized tribes, including
Dual eligibles members of the Eastern Band of Cherokee Indians
9Overview of Standard Plan Enrollment
Medicaid beneficiaries eligible for Standard Plans will enroll in two phases
based on the region where they live*
June July Sept. Oct. Nov. Dec. Feb.
2019 2019 2019 2019 2019 2019 2020
Phase 1
Phase 2
Enrollment Open Managed Care Managed Care
Notices Sent Enrollment Implementation Implementation
Ends
Open Open Open
Enrollment Enrollment Enrollment
Begins Begins Ends
*See Appendix for regions 10Plan Selection for Current Medicaid Beneficiaries
Beneficiaries will receive notification letters with
New Medicaid
instructions on enrolling in managed care
beneficiaries will be able
to select a plan outside of
Beneficiaries will have 60 days to select plans during
open enrollment
open enrollment
Beneficiaries can enroll in a plan via phone, online,
paper or in-person
Beneficiaries who do not select a plan during open
DHHS’ enrollment broker
enrollment will be auto-assigned to a plan based on an
is available to assist
algorithm
members during the plan
selection process
Beneficiaries have 90 days after plan enrollment to
switch plans “without cause;” after that, they may
switch only for certain reasons or annually
11PCP Selection
Advanced Medical Home/Primary Care Provider Selection
Under managed care, beneficiaries may choose their Advanced Medical Home
(AMH)/primary care provider (PCP)
The enrollment broker will provide beneficiaries with information and assistance in
selecting their AMH/PCP at the time of PHP enrollment (e.g., answer beneficiary
questions about which AMHs/PCPs are in-network for different PHPs)
Subsequent changes to AMH/PCP assignment are managed by the beneficiary’s
PHP
Beneficiaries can change their AMH/PCP without cause within 30 days of selection
or notification of assignment, and up to one additional time every 12 months
Beneficiaries may change their AMH/PCP with cause at any time
13AMH/PCP Auto-Assignment
PHPs will assign beneficiaries to an AMH/PCP if they do not select an AMH/PCP
Beneficiaries that do not select a AMH/PCP during the plan selection period will be
assigned a AMH/PCP by the PHP in which they enroll
AMH/PCP auto-assignment will consider: If members want to
Beneficiary claims history change their PCP,
Family member AMH/PCP assignment providers should
instruct them to call
Geography their PHP’s member
Special medical needs services department
Language/cultural preference
These are the only items a PHP is
allowed to consider for auto-
assignment at this time but the State
may add additional items in the future
14Beneficiary Supports
Role of the Enrollment Broker
The enrollment broker will provide choice counseling, enrollment assistance and
education to beneficiaries
Enrollment Broker Responsibilities
Leading outreach and education efforts, including:
Developing and disseminating educational materials
Hosting outreach events during open enrollment period
Providing enrollment assistance and choice counseling to support beneficiaries’
plan and AMH/PCP selection by offering specific details about each plan, including:
Provider directory with information about whether beneficiaries’ preferred
providers are in network
Plan comparison chart for key quality or operational metrics
Processing enrollments and disenrollments and transmitting to the state
Maintaining a call center to assist beneficiaries with enrollment related requests
16Role of the Member Ombudsman
Providers should be aware that there will be a member ombudsman responsible for
helping patients navigate issues with managed care
Ombudsman’s Responsibilities
Provide information and education to assist beneficiaries with access to care
Serve as a central resource to resolve issues within the Medicaid Managed
Care delivery system
Does not impede a beneficiary’s right to file a grievance with a PHP,
contractor or the state
Refer beneficiaries to external entities that assist Medicaid beneficiaries
regardless of delivery system (e.g., PHPs, enrollment broker, local DSS
agencies and other community-based organizations)
Monitor trends related to access to care to support DHHS oversight of the
Medicaid managed care program
17PHP Member Services
PHPs must maintain a member services department; providers can also refer
patients to their PHP’s member services department to resolve issues
Member Services’ Responsibilities:
Assist members in selecting or changing PCP/AMH
Educate and assist beneficiaries with obtaining services under Medicaid
managed care, including out-of-network services
Field and respond to beneficiaries questions and complaints
Advise and assist beneficiaries with navigating the appeals, grievance and
state fair hearing process
Maintain:
Member facing service line
Website
Handbook
18Grievances, Appeals, and Other
Consumer ProtectionsAppeals and Grievances
Beneficiaries will have rights to file grievances and appeals against their PHPs and must
exhaust the internal appeals process before using the state fair hearing process
Grievances Appeals
Beneficiaries will be able to file a Beneficiaries must be able to appeal an
grievance, or complaint, at any time, adverse benefit determination with their PHP
orally or in writing with their PHP by phone, writing or in person within 60 days
of notification
PHPs must generally resolve the
grievance within 30 calendar days of PHPs must resolve appeals within 30 days for
receipt and within 5 days if it relates to standard requests and 72 hours for expedited
the denial of an expedited appeal requests where a standard appeal could
request jeopardize the beneficiary’s life, physical or
mental health or ability to maintain or regain
State will monitor grievances for trends maximum function
PHPs must continue to pay for benefits during
the appeal under specified circumstances
Clinical policies webinar on 6/13 will cover appeals in more detail
20Other Consumer Protections
DHHS has set certain marketing rules with which PHPs must comply to avoid unfairly
steering beneficiaries to their plans; providers should be aware of these rules
PHPs may: PHPs may not:
• Display marketing materials at community • Engage in door-to-door, telephone, email,
centers, markets, malls, retail establishments, texting or other cold-call marketing
hospitals, pharmacies, other provider sites, activities
schools, health fairs, and public libraries • Misrepresent covered or available
• Participate in community based events or services, enrollment benefits, availability
activities or skills of network providers
• Sponsor outreach activities and events • Offer gifts or incentives to enroll expect as
• Conduct media campaigns allowed in the contract
• Display or conduct marketing activities in
health care settings, except in common
DHHS will monitor all marketing activities
areas
for compliance; providers that have
Providers may display
questions about a PHP’s marketing
PHP marketing material
activities can refer that question to DHHS
in common areas and
other approved places
21Promoting Healthy Opportunities
Addressing Beneficiaries’ Unmet Resource Needs
Providers that identify a patient with an unmet resource need can refer that
patient to their PHP or AMH provider for help with non-medical services
• DHHS is committed to providing a well-coordinated system of care that addresses the medical and non-
medical drivers of health—often referred to as the “social determinants of health.” DHHS has identified
four priority domains: Housing, Food, Transportation and Interpersonal Violence/Toxic Stress.
• PHPs will be responsible for addressing non-medical and social factors that impact beneficiaries’ health
by:
• Assessing for unmet resource needs as part of the Care Needs Screening
• Have a housing specialist on staff
• PHPs must contract with local care management entities (e.g., Tier 3 AMHs and Local Health
Departments) to:
• Connect beneficiaries to needed social resources using NCCARE360, a statewide coordinated
network and referral platform
• Provide additional support for high-need cases, such as assisting with filling out a SNAP application
or connecting the beneficiary to medical-legal partnership
23Healthy Opportunities Pilots
Beneficiaries in select regions will have access to additional benefits
aimed at addressing their social needs
North Carolina received approval from CMS to implement “Healthy Opportunities Pilots”
The Pilots will test evidence-based interventions designed to reduce costs and improve health by more
intensely addressing housing instability, transportation insecurity, food insecurity, interpersonal
violence (IPV) and toxic stress
Pilot services include:
Housing: Tenancy support and sustaining services, securing housing payments, short-term post
hospitalization services
Food: Food support and meal delivery services
Transportation: Non-emergency health-related transportation
IPV/Toxic Stress: Child-parent support and IPV and parenting support resources
PHPs will play a central role in managing the Pilots—including by helping to identify eligible members,
identifying which Pilot services they need and paying for the services
Additional details to be released later in 2019
24Contents
North Carolina Medicaid Managed Care Transformation
Deep Dive: Beneficiary Policies
More Opportunities for Engagement
Q&A
Appendix
25More Opportunities for Engagement
DHHS values input and feedback and is making sure stakeholders have the opportunity to
connect through a number of venues and activities.
Ways to Participate
Regular webinars, conference calls, meetings, and conferences
Comments on periodic white papers, FAQs, and other
publications
Regular updates to website:
https://www.ncdhhs.gov/assistance/medicaid-transformation
Comments, questions, and feedback are all very welcome at
[email protected]
Providers will receive education and support
during and after the transition to managed care.
26Upcoming Events
Upcoming Managed Care Webinar Other Upcoming Events
Topics
• Virtual Office Hours (VOH): Running
• Behavioral Health Services: Standard bi-weekly, as of April 26th
Plans and Transition Period (5/23)
• Provider/PHP Meet and Greets:
• AMH Contracting with PHPs (5/30) Regularly hosted around the State
• Clinical Policies (6/13)
• Healthy Opportunities in Medicaid Schedule for VOH and Meet & Greets
Managed Care (6/27) available on the Provider Transition to
Managed Care Website
Look out for more information on upcoming events and webinars distributed regularly
through special provider bulletins
27Contents
North Carolina Medicaid Managed Care Transformation
Deep Dive: Beneficiary Policies
More Opportunities for Engagement
Q&A
Appendix
28Q&A
Contents
North Carolina Medicaid Managed Care Transformation
Deep Dive: Beneficiary Policies
More Opportunities for Engagement
Q&A
Appendix
30Two-Phased Managed Care Roll-out By Region
REGION 2 REGION 4 REGION 6
NOV. 2019 NOV. 2019 FEB. 2020
ALLEGHANY
ASHE NORTHAMPTON
SURRY WARREN GATES
STOKES ROCKINGHAM CASWELL PERSON
GRANVILLE
VANCE HERTFORD
REGION 1
HALIFAX
WATAUGA WILKES
YADKIN
ALAMANCE
FORSYTH
DURHAM
ORANGE
AVERY GUILFORD FRANKLIN BERTIE
FEB. 2020
NASH
CALDWELL DAVIE
YANCEY ALEXANDER EDGECOMBE
MADISON
IREDELL DAVIDSON MARTIN WASHINGTON
WAKE TYRRELL DARE
BURKE CHATHAM WILSON
RANDOLPH
MCDOWELL CATAWBA ROWAN
BUNCOMBE PITT BEAUFORT
HAYWOOD
JOHNSTON
SWAIN LINCOLN GREENE HYDE
RUTHERFORD LEE
CABARRUS
HENDERSON HARNETT WAYNE
GRAHAM
JACKSON STANLY MOORE
POLK CLEVELAND GASTON
LENOIR CRAVEN
MECKLENBURG MONTGOMERY
MACON TRANSYLVANIA
CHEROKEE
CLAY CUMBERLAND JONES PAMLICO
SAMPSON
REGION 3
RICHMOND HOKE
UNION
ANSON
DUPLIN
ONSLOW CARTERET
SCOTLAND
FEB. 2020 ROBESON BLADEN
PENDER
REGION 5
COLUMBUS
BRUNSWICK
FEB. 2020
Rollout Phase 1: Nov. 2019 – Regions 2 and 4
Rollout Phase 2: Feb. 2020 – Regions 1, 3, 5 and 6
Contract Year 1 runs through June 30, 2020 for all regions
31Plan Selection and Auto-Assignment
DHHS will auto-assign those that do not choose a plan according to a transparent process
Plan Auto-Assignment
The State will auto-assign all beneficiaries who do not select a plan according to the following algorithm:
Beneficiary’s geographic location Equitable plan distribution with enrollment
Beneficiary’s membership in a special subject to:
population (e.g., member of federally PHP enrollment ceilings and floors, per
recognized tribes or BH I/DD Tailored Plan PHP, to be used as guides
eligible) Increases in a PHP’s base formula based
PCP/AMH selection upon application and on their contributions to health-related
PCP/AMH historic relationship resources
Plan assignments for other family members Intermediate sanctions or other
Previous PHP enrollment during previous 12 considerations defined by the Department
months (for those who have “churned” on/off that result in enrollment suspensions or
Medicaid managed care) caps on PHP enrollment
Note: *Certain populations may be able to change PHPs more frequently. Additionally, beneficiaries may change PHPs “with cause” at any time. More details available in enrollment
32
broker RFP, available at: https://files.nc.gov/ncdma/documents/Transformation/RFP%2030-180090%20-%20Enrollment%20Broker%20Services%20-%20Final%20%283-2-18%29.pdfYou can also read
