1. Medicaid Transformation: A Changing System.
NCAPSE Spring Conference
Julia Adams Scheurich

2. How Medicaid funds flow to NC today
NCGA
HHS – Federal Health and Human Services
CMS - Centers for Medicaid Services (Federal)
DHHS – Department of Health and Human Services (State of NC)
LME - Local Management Entities/ MCOs - Managed Care Organizations (County/Local)
Service Providers (of which UNC, Autism Society, etc. are one of many)
NC Medicaid /Division of Voc Rehab/Division of MH/DD/SAS (State)
Reminder and level setting
Explain the flow and the NCGA (i.e. waiver slots and PMPM)

3. Vision for Medicaid Managed Care - DHHS
“Improving the health and well-being of North Carolinians through an innovative, whole-person centered and well- coordinated system of care that addresses both medical and non-medical drivers of health.”
Vision for Medicaid Managed Care - DHHS

4. Medicaid Transformation = Change is coming
Requires Medicaid to move to an at risk, capitated, managed care 1115 waiver
1115 waiver is the federal authority used to accomplish the foundations set forth in the state law
We currently operate under the 1915b/c waiver
Moves away from a fee for service model for services outside of the LME/MCO.
Vision of reform is to deliver whole-person care through coordinated physical health, behavioral health, intellectual/developmental disabilities and pharmacy products and care models.
Includes Social Determinants of Health.
Address the full set of factors that impact health, uniting communities and health care systems
Medicaid Transformation = Change is coming
At risk, capitated, managed care BILLIONs of dollars –hospitals, MDs, and the Behavioral Health system

5. Other huge piece of 1115 – exploration to address health barriers, pilots/grants to come out soon around Employment, Housing, Food Insecurity, transportation, personal safety. Grants to come out for these soon also. DSS having to step up, everyone having to prove their value.

6. 2015: Session Law 2015-245 directs the Department to transition to managed care
: Extensive collaboration with and feedback from stakeholders
Aug 2018: RFP released
Oct 2018: CMS approves 1115 waiver
Feb 2019: Contracts Awarded to PHP.
How did we get here?

7. PHPs for NC Medicaid Managed Care for Standard Plans
Statewide contracts
AmeriHealth Caritas North Carolina, Inc.
Blue Cross and Blue Shield of North Carolina, Inc.
UnitedHealthcare of North Carolina, Inc.
WellCare of North Carolina, Inc.
Regional contract – Regions 3 & 5
Carolina Complete Health, Inc.

8. NC Medicaid Managed Care Regions and Rollout Dates – DHHS Standard Plans
NOV. 2019
REGION 4
NOV. 2019
REGION 6
FEB. 2020
ALLEGHANY
ASHE
SURRY
NORTHAMPTON
STOKES
ROCKINGHAM
CASWELL
PERSON
GRANVILLE
WARREN
GATES
VANCE
REGION 1
FEB. 2020
HALIFAX
HERTFORD
WATAUGA
WILKES
YADKIN
FORSYTH
ALAMANCE
AVERY
GUILFORD
ORANGE
DURHAM
FRANKLIN
BERTIE
ALEXANDER
IREDELL
NASH
MADISON
YANCEY
CALDWELL
DAVIE
EDGECOMBE
DAVIDSON
MARTIN
WASHINGTON
TYRRELL
BURKE
CHATHAM
WAKE
DARE
WILSON
BUNCOMBE
MCDOWELL
CATAWBA
ROWAN
RANDOLPH
HAYWOOD
PITT
BEAUFORT
SWAIN
LINCOLN
JOHNSTON
RUTHERFORD
LEE
GREENE
HYDE
HENDERSON
CABARRUS
GRAHAM
HARNETT
WAYNE
JACKSON
POLK
CLEVELAND
GASTON
STANLY
MOORE
LENOIR
CRAVEN
CHEROKEE
MACON
TRANSYLVANIA
MECKLENBURG
MONTGOMERY
CLAY
REGION 3
FEB. 2020
RICHMOND
HOKE
CUMBERLAND
SAMPSON
JONES
PAMLICO
UNION
ANSON
DUPLIN
SCOTLAND
ONSLOW
CARTERET
ROBESON
BLADEN
PENDER
REGION 5
FEB. 2020
COLUMBUS
BRUNSWICK
Rollout Phase 1: Nov – Regions 2 and 4
Rollout Phase 2: Feb – Regions 1, 3, 5 and 6

10. Feb March April 2019 May June 3RD July Aug Sept Oct Nov 1ST Dec
Initial letter sent to beneficiaries in 2 counties
Address verification letter sent to remaining counties
2019
Flyers posted at DSS
Address corrections to DSS
2nd letter to members
Member Outreach activities
Public Service Announcements
PHP marketing materials
June 3RD
EB Call Center Open
Welcome Packets mailed
SOFT LAUNCH
July Aug
Sept Oct
Open Enrollment Begins - July 15th
Open Enrollment Ends - Sept 13th
Members auto assigned to PHPs based on algorithm
• Member ID cards
Member Handbooks
Nov 1ST
Day 1 -
Regions 2
& 4
Managed Care Launch- Phase 1
Dec
Member feedback
Evaluation of materials, process

11. June 3RD July 2019 Aug Sept 2 Oct Nov Dec Jan 2020 Feb 1st March nd
EB Call Center Open
Outreach Activities
Flyers posted at DSS
Address corrections to DSS
Letters to members
Member Outreach activities
SOFT LAUNCH
Sept 2 nd
Enrollment Welcome Packets
Oct Nov Dec Jan
Open Enrollment Begins- Oct 14th
Open Enrollment Ends- Dec 13th
2020
Day 1 -
Regions 1,
3, 5 & 6
• Member ID cards
Member Handbooks
Feb 1st
Managed Care Launch- Phase 2
March
Member feedback
Evaluation of materials, process

12. How will people know which plan we are in?
This Photo by Unknown Author is licensed under CC BY-NC-ND

13. Maximus: The Role of the Enrollment Broker
Independent of the PHPs.
Will help people decide which plan they should be in.
There is an auto assignment into the plans but there is choice.
Won an RFP to do this work in NC.
Maximus: The Role of the Enrollment Broker

14. Beneficiary Experience – Auto Assignment
Beneficiaries who don’t choose a health plan will be assigned one automatically, consistent with the following components in this order:
Where the beneficiary lives.
Whether the beneficiary is a member of a special population (e.g. member of federally recognized tribes or BH I/DD Tailored Plan eligible).
If the beneficiary has a historic relationship with a particular PCP/AMH.
Plan assignments of other family members.
If the beneficiary has a historic relationship with a particular PHP in the previous twelve (12) months (e.g.,“churned” off/into Medicaid Managed Care). 9

15. The Prepaid Health Plans: Benefits
Both Standard Plans and BH I/DD Tailored Plans will be integrated managed care products and will provide a robust set of physical health, behavioral health, long-term services and supports, and pharmacy benefits. Create single point of accountability for care and outcomes for Medicaid.
Standard Plans Tailored Plans
Beneficiaries benefit from integrated physical & behavioral health services
“Primary care” behavioral health spend included in PHP capitation rate
Phased implementation –
Nov & Feb. 2020
Specialized managed care plans targeted toward populations with significant BH and I/DD needs
Access to expanded service
array
Behavioral Health Homes
Projected for July 2021 3

16. Standard Plan Medical services: physician healthcare. Pharmacy.
PT, OT, Speech Therapy.
Dietician services.
Behavioral Health. (Low to moderate)
Substance Use Disorder Services. (Low to moderate)
EPSDT
Autism Services Under State Plan

17. Tailored Plan All Medicaid benefits (minus dental, LEA, PACE) PLUS
Residential treatment facility services
Child and adolescent day treatment services
Intensive in-home services
Multi-systemic therapy services
Psychiatric residential treatment facilities (PRTFs)
Assertive community treatment (ACT)
Community support team (CST)
Substance abuse non-medical community residential treatment
Substance abuse medically monitored residential treatment
• Intermediate care facilities for individuals with intellectual disabilities (ICF/IID)
WAIVER SERVICES
TBI waiver services
• Innovations waiver services
• 1915(b)(3) services ALL STATE-FUNDED BH & I/DD SERVICES STATE-FUNDED TBI SERVICES

18. Tailored Plan Design and Launch Timeline
Until early 2020, DHHS will be conducting intensive planning for both Standard Plans (SPs) and TPs.
After SPs launch, DHHS will continue implementation planning for Tailored Plans.
Aug.
Jan.
Feb.
Nov.
May
July
2018
2019
2020
2021
BH I/DD TP design
(8/2018-2/2020)
BH I/DD TP implementation planning
(2/2020-7/2021)
SP implementation planning
(8/2018-2/2020)
DHHS awards BH I/DD TP contracts (tentative)
DHHS released SP RFP
SPs launch in initial regions
BH I/DD TPs
launch
(tentative)
SPs launch in remaining regions;
DHHS releases BH I/DD TP RFA
(tentative)
DHHS issues SP contracts
MCAC BH/IDD SUBCOMMITTEE, FEB. 4, 2019

19. Tailored Plan Eligibility
Qualifying I/DD diagnosis Innovations and TBI Waiver enrollees and those on waitlists
Qualifying Serious Mental Illness (SMI) or Serious Emotional Disturbance (SED) diagnosis who have used an enhanced service Those with two or more psychiatric inpatient stays or readmissions within 18 months
Qualifying Substance Use Disorder (SUD) diagnosis and who have used an enhanced service
Medicaid enrollees requiring TP-only benefits
Transition to Community Living Initiative (TCLI) enrollees
Children with complex needs settlement population
Children ages 0-3 years with, or at risk for, I/DDs who meet eligibility criteria
Children involved with the Division of Juvenile Justice of the Department of Public Safety and Delinquency Prevention Programs who meet eligibility criteria
NC Health Choice enrollees who meet eligibility criteria

20. Tailored Plan Simplified
What services are in the standard plan for people with I/DD, MH or SUD?
Behavioral Health Urgent Care • Outpatient Plus • Rapid Care Services • Behavioral Health Crisis Assessment and Intervention • Child First Outpatient
EPSDT (both plans)
RBBHT –State Plan Services for children and young adults with Autism. Age This is ABA. (both plans)
Care management.
SDOH through NCCARES 360, Healthy Opportunities Pilots, and what the PHPs have internally that they will bring to NC.
Tailored Plan Simplified

21. Tailored Plan Simplified
What services will remain in the tailored plan?
Innovations waiver.
B3.
ILOS (except for ones that are specifically for the standard plan)
Behavioral Health Urgent Care • Outpatient Plus • Rapid Care Services • Behavioral Health Crisis Assessment and Intervention • Child First Outpatient
State dollar services.
ICF/IDD
Intensive services for mental health, substance use disorders, PRTF, residential.
Tailored Plan Simplified

22. Tailored Plan Simplified
Is there choice in which plan a person can enroll in?
Yes and No
Can I go to the standard plan and stay on the Innovations waitlist?
Yes. You will not loose your place on the waitlist.
Can I go to the standard plan and keep my Innovation waiver, B3, ILOS, or Single Stream Services?
No. You would loose your tailored plan services.
Tailored Plan Simplified

23. How can I learn more about the tailored plans?
DHHS has a lot of information:
Behavioral Health/IDD Tailored Plan: idd-tailored-plans
Has link to all the previous webinars including the slides and a transcript of the presentations.
Link to the Eligibility and Enrollment Paper: FinalPolicyGuidance-Final pdf
Next white paper from DHHS will be on care/case management.