North Carolina’s Design for Medicaid

In August, 2017, the North Carolina Department of Health and Human Services (DHHS) published a report detailing their proposed program design for Medicaid managed care. DHHS is going to transition Medicaid from a fee-for-service structure to a managed care structure. DHHS is preparing to launch Medicaid managed care in 2019 and will work with stakeholders and experts to refine program details.

The current Medicaid policy reimburses a broad array of providers for services rendered via telemedicine at the same rates as in-person visits when both beneficiaries and providers are located at Medicaid-enrolled sites.

The use of technology will play an important role in continuing to deliver the state as the transition from fee-for-service to Medicaid managed care will require new infrastructure and protocols for claims data collection, exchange, and analysis.

Prepaid Health Plans (PHP) will be encouraged to support the use of telemedicine as a tool for ensuring access to needed services. When a PHP enrollee requires a medically necessary service that is not available within the PHP network, the PHP may provide access to the service via telemedicine.

DHHS also plans to encourage PHPs to implement pilots that test additional telemedicine strategies and will invite PHPs to propose innovative pilots related to telemedicine in their responses to DHHS Medicaid managed care procurement.

DHHS plans to work with PHPs, providers, and other stakeholders to develop a comprehensive strategy related to telemedicine. This strategy will include using not only telemedicine, but also using smart home technology and assistive technology to help the aging population and to provide access to care in underserved areas.

Providers in the state currently have access to a range of information systems that support management and coordination of patient care. These tools include the NC HealthConnex Clinical Portal and CCNC’s Care Management Information System (CMIS), provider portals, and quality performance reports. A key decision will be made on the functions that DHHS should conduct directly through a contracted vendor or through PHPs with DHHS guidance.

DHHS will work with stakeholders to establish communication between parties involved in encounter data exchange and also to plan for other types of information exchange and the reporting which may be required.

DHHS plans to combine various data sets to produce data on maternal and child health, outcome measures, and measures related to infectious diseases. DHHS is also exploring developing a standardized social needs screening instrument with a focus on food insecurity, housing instability, and transportation. The plan is to integrate this data with physical and behavioral health services.

In addition, North Carolina will build on current resource management databases to include an up-to-date list of all benefits and community services. DHHS intends to work with key stakeholders to establish the source and structure of inputs to be entered into a resource management database.

Go to to view the report titled “North Carolina’s Proposed Program Design for Medicaid Managed Care” August 2017.

Share Button