Managed care coming to North Carolina Medicaid

Oct. 18--A quiet revolution is coming to North Carolina's Medicaid coverage in 2019. Officials say most patients and providers will barely notice the difference, but they might have to make some extra choices.

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. The idea is to cut Medicaid costs and increase efficiency of service. Jay Ludlam, assistant secretary for Medicaid transformation in the state Department of Health and Services, said he thinks managed care will make Medicaid more sustainable and its costs more predictable.

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 patients 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.

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.

Providers are expected to contract with more than one PHP. The PHPs, rather than the state, will then pay them for covered services they provide and resolve any payment issues.

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.

Established in 1965, Medicaid is a government insurance program that provides free or low-cost health coverage to many low-income families and children, pregnant women, the elderly, and those with disabilities. Although heavily funded by the federal government, the program is administered by the individual states.

By 2014, more than half the states had adopted some form of managed care, with more than 55 million patients covered. The N.C. General Assembly voted to adopt a managed care plan in 2015.

Reporter Ben Steelman can be reached at 910-343-2208 or [email protected].

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