Tailored Plan Provider Manual and Webinar

DHHS has released its BH I/DD Tailored Plan Provider Manual for Tailored Care Management as well as the application questions that providers will be required to answer. While the implementation of managed care has been suspended as legislative action is needed to move forward, the Department continues to work on the design of Tailored Plans. One of the Department’s key areas of focus in Medicaid Transformation is building robust and effective models for managing beneficiaries’ comprehensive needs
through local care management. Provider-based care management will promote whole-person care, foster high-functioning integrated care teams, and drive towards better health outcomes. Additional information can be accessed on DHHS website- Tailored Plan information, the manual, and the application questions.
DHHS will host a webinar for providers entitled Tailored Care Management: What Providers Need to Know on December 18 from 11:30am-12:30pm. This webinar will explore the provider manual in more detail, walk through the application process, and address questions for you to consider. Register here.

Legislators Adjourn Without Taking Actions Required for Medicaid Managed Care; DHHS Suspends Implementation of Managed Care


Nov 19, 2019

The North Carolina Department of Health and Human Services today announced that because the NC General Assembly did not take needed action, managed care implementation and open enrollment for NC Medicaid must be suspended. The General Assembly adjourned last week without providing required new spending and program authority for the transition to managed care. Managed care will not go live on Feb. 1, 2020.

With managed care suspended, NC Medicaid will continue to operate under the current fee-for-service model administered by the department. Nothing will change for Medicaid beneficiaries; they will get health services as they do today. Behavioral health services will continue to be provided by Local Management Entities/Managed Care Organizations. All health providers enrolled in Medicaid are still part of the program and will continue to bill the state through NCTracks.

Open enrollment had begun for part of the state in July and launched statewide in October. The North Carolina Enrollment Broker Call Center (833-870-5500) will stay open through Dec. 13, 2019 to answer questions but will no longer enroll beneficiaries in a health plan. Beneficiaries can continue to contact the Medicaid Contact Center (888-245-0179). Notices will be sent to beneficiaries informing them to continue accessing health services as they do now, rather than through new health plans.

The suspension of work and the wind-down process will begin tomorrow. Once suspended, managed care cannot easily or quickly be restarted. The department will not decide on a new go-live date until it has program authority within a budget that protects the health and safety of North Carolinians and supports the department’s ability to provide critical oversight and accountability of managed care.

Both the conference and transformation mini budgets passed during this year’s legislative session and vetoed by Governor Roy Cooper left the department vulnerable to an unprecedented cut that would have had a crippling effect on its ability to provide services that protect people’s health and safety and moved the department out of Raleigh to Granville County. In addition, neither expanded Medicaid so that hardworking North Carolinians could afford access to health coverage.

In 2015, the NC General Assembly enacted legislation directing DHHS to transition Medicaid and NC Health Choice from fee-for-service to managed care. Under managed care, the state contracts with insurance companies, which are paid a predetermined set rate per person to provide all services. The department was on track to go live Feb. 1, 2020. New funding and program authority was required from the General Assembly to meet this timeline. 

What is Medicaid Transformation?

The North Carolina Department of Health and Human Services is dedicated to improving the health and well-being of all North Carolinians. In support of this goal, the Medicaid and NC Health Choice programs are transitioning to Medicaid Managed Care this year. This is the most significant change to the NC Medicaid program in over 40 years.

Beneficiaries will transition to one of two types of prepaid health plans (PHP’s), customized to the population they serve.

The two plans are Standard Plans and Tailored Plans.

Standard Plans will launch starting in July 2021 and they will serve the vast majority of Medicaid beneficiaries.

Behavioral Health and Intellectual/Developmental Disability (BH/IDD) Tailored Plans will launch in July 2022 and will serve individuals with more serious behavioral health disorders (serious mental illness (SMI), serious emotional disturbance (SED), and/or substance abuse disorders (SUD), intellectual/developmental disabilities (I/DDs), and traumatic brain injuries (TBIs).