In 2015, the North Carolina General Assembly enacted legislation that would fundamentally change the Medicaid program in North Carolina. Since then, the N.C. Department of Health and Human Services has worked to design a transformation model that would move the administration of the program into risk-based comprehensive managed care, shift greater responsibility for population health management to primary care providers, and change the way that health care providers are paid in the Medicaid program.
After what feels like an eternity, Medicaid Transformation will begin July 1, 2021. Yes, it actually will. I know there are some eye rolls out there and “yeah sures” but as far as we at Atromitos can tell, the Department is committed to this start date. We adamantly appeal to providers, Medicaid enrollees, and other stakeholders to educate yourselves on the transformation model and engage in the process so that you are ready and in the best positions when managed care launches in North Carolina. Because July 1st doesn’t just signal “big change,” but continued change.
Here, in the Greater Wilmington area (Medicaid Region 5) we will have five prepaid health plans (PHPs): UnitedHealthcare Community Plan, Healthy Blue (Blue Cross NC), Carolina Complete Health, WellCare of North Carolina, and AmeriHealth Caritas of North Carolina. In the coming months, patients will work with Medicaid enrollment brokers to select a plan (or determine if a previously selected plan is still right for them). For providers, preparing for Medicaid Transformation will require more legwork. First, if you signed a network participation agreement with plans in the “before times” (before suspension, before COVID), we applaud you. However, it is time to take those out and determine if changes are needed. 2019 was at least 10 COVID years ago and things have changed quite a lot, not least as a result of some last-minute programmatic changes.
It is important for providers to understand that during the suspension, the Department didn’t stop working on elements of Transformation. They used this time to determine what changes would be beneficial and began announcing such changes at the end of 2020. Key changes to the Advanced Medical Home Tier 3 program are critical for providers to understand. We highlight a few here:
1. Streamlined Reporting: The Department seeks to reduce reporting variance. For that reason, they have reduced the number and types of quality and care management performance measures that must be reported and will be introducing a standardized reporting template for care management (expected to be released soon). The Department has also removed performance penalties for failure to meet certain care management processes and timelines.
2. Care Management Fees and Incentive Payments: One of the biggest points of contention in 2019 and 2020 was the fees that the PHPs proposed to pay for care management delivered by AMH Tier 3 practices. Many of the PHPs imposed risk-based payments as a part of those fees, which were routinely too low for providers to have adequately performed services required by the AMH program. The Department has since made clear that the PHPs should be paying higher rates that are sufficient to cover the actual cost of delivering the integrative care management model at the core of the Advanced Medical Home. Furthermore, the Department has prohibited placing care management fees “at risk.” Instead, if PHPs want to provide incentive payments in addition to the fees, they may do so. This change alone is a reason many agreements will need to be renegotiated.
3. AMH Glide Path: To entice providers to participate as AMH Tier 3 providers, as well as to alleviate some of the investment cost required to become an AMH Tier 3, the Department will make available incentive payments of $8.51 PMPM to eligible providers that have attested to AMH Tier 3. To be eligible, an attested AMH Tier 3 provider must (1) have contracted with at least 2 PHPs, and (2) have successfully complete data testing with those PHPs. These payments are available for two months before “go-live” and will be based on the practices existing Medicaid patient panel in CarolinaACCESS.
4. PHP Discretion in Downgrading AMH Tier 3 Practices: Previously, PHPs would not be permitted to downgrade an AMH Tier 3 practice for failure to meet performance expectations for the first 90-days post go-live. The Department has removed this requirement and PHPs will be able to downgrade at their discretion after a corrective action period.
These changes mean that PHPs have new AMH Tier 3 agreements. Providers will need to engage with the PHPs to obtain the new state reviewed templates and negotiate updated terms. The Department is issuing new guidance and information regularly. Keep track of these updates at https://medicaid.ncdhhs.gov/transformation.
Michealle Gady, JD, is Founder and President of Atromitos, LLC, a boutique consulting firm headquartered in Wilmington, North Carolina. Atromitos works with a variety of organizations from health payers and technology companies, to community-based organizations and nonprofits but their work reflects a singular mission: creating healthier, more resilient, and more equitable communities. Michealle takes nearly 20 years’ experience in health law and policy, program design and implementation, value-based care, and change management and puts it to work for Atromitos’ partners who are trying to succeed during this time of dramatic transformation within the U.S. healthcare system. Outside of leading the Atromitos team, Michealle serves as a Board Member for both the Cape Fear Literacy Council and A Safe Place and is a member of the American College of Healthcare Executives and American Health Law Association.
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