1. North Carolina MEDICAID TRANSFORMATION Update for Local Public Health Departments
The website at the bottom of this title page it the primary location where all DHB Medicaid Transformation information is kept.

2. North Carolina’s Vision for Medicaid Transformation
“To improve the health of North Carolinians through an innovative, whole-person centered, and well-coordinated system of care that addresses both the medical and non- medical drivers of health.”
This is our vision for what we are building toward.
Conducted extensive stakeholder engagement in design process
In support of this vision most Medicaid and NC Health Choice programs will transition to Medicaid Managed Care February 2020—this is the most significant change to the NC Medicaid program in over 40 years.
MEDICAID MANAGED CARE WEBCAST | July 15, 2019

3. Region 2 Feb 2020 Region 4 Feb 2020 Region 6 Feb 2020 Region 1
DHHS recently announced that it would extend open enrollment for Medicaid beneficiaries and move to a statewide transition to managed care on February 1, 2020.  As you know, managed care was scheduled to roll out in two phases, with part of the state beginning managed care services on November 1, 2019 and most of the state beginning on February 1,  
The timeline has been adjusted because DHHS cannot implement critical actions to go-live with managed care under the current continuing resolution budget.  The updated timeline only impacts counties that were in Phase 1; it does not impact counties that were scheduled for Phase 2.  Thus, the date of February 1, 2020 for statewide implementation remains unchanged.
At this time nearly 2,800 individual practices across the state are certified to participate as AMHs, and nearly 1,500 have certified to participate in AMH Tier 3 since the certification process began in October, These practices range from large health systems to small independent practices and local health departments. This graphic gives the footprint of the AMH program across the state
PLE
Region 5
Feb 2020

4. What and who are included in managed care?
So what beneficiaries are to be enrolled in which plans.

5. $40,000 in Fee for Service
$40,000 in Cost Settlement
$40,000 in CC4C & OBCM

6. DHHS Overarching Goal – to hold county funding flat with transformation (assuming constant utilization).
PHPs are required to contract with LHD Care Management Programs, at the same per member, per month (PMPM) rate.
PHPs are required to contract with all essential providers, including LHDs.
Adding Utilization Based Payments to offset losses in Cost Settlement.
Maintaining current LHD fee schedule as the rate floor.

7. Local Health Departments (LHD) and the Evolution of Existing Programs Under Managed Care
Pre-Transformation: (now called)
NC Medicaid Direct
Post-Transformation: Managed Care
Medicaid Provider – All LHDs
Medicaid Provider – All LHDs
Carolina ACCESS
Advanced Medical Home
Pregnancy Management Program (PMP)
Pregnancy Medical Home
Care Coordination for Children (CC4C)
Care Management for At-Risk Children (CMARC)
Local Health Departments are considered Essential Community Providers. Of the 85 health departments, about 58 have been participating in the Carolina Access program and will transition into Advanced Medical Home model. 41 of the 58 health departments have attested that they will be participating as a Tier 3 AMH provider, which essentially means that they will provide a primary care medical home for adults and/or children. As a quick definition of what an advanced or primary care medical home really means… the health department is listed on the beneficiaries’ Medicaid card, they provide annual physicals as well as sick visits and are available to address their patient’s concerns after-hours. But LHDs provide Medicaid services to a much broader population – examples of these services include immunizations (many small, rural providers do not participate in VFC and cannot afford to stock vaccines, due to costs, so those patients may come to the LHD for immunizations. Family Planning, Communicable Disease, prenatal care – those are other examples of services that may be provided at the LHD.) So we predict that the Medicaid services provided outside the patient’s primary care medical home will remain in the LHDs’ book of business.
About 20-30% of the population for CC4C is expected to remain in FFS. Most of the population eligible for high risk pregnancy care management are expected to move into managed care– generally only women who are TP-eligible will remain in FFS for pregnancy care management.
Q: On this slide there is a comment out to the side “this is OK!” 
I assume this is indicating that Tier 1 & 2 will still cover services even if the LHD is not an AMH.  However, a question that keeps coming up is “what if we are Tier 1 now and in two years still don’t qualify to be a Tier 2.  What happens then?  These LHDs would be out-of-network right?  What would be their payment structure from the PHP at that point. 
A: When tier 1 and 2 are phased out, those providers will no longer be listed as a medical home provider – so the provider name will not be on the Medicaid card and the provider will not get PMPM or any additional quality-based payments.  Those providers will continue to be Medicaid providers and will bill the PHPs ( that they have contracts with) just not as a medical home.
Obstetric Care Management (OBCM)
Care Management for High- Risk Pregnancy (CMHRP)
Note: These programs will remain in place post-transformation for populations that remain in Medicaid Direct coverage
Note: Local Health Departments, Pediatric providers and Maternity Care providers can also be AMH providers

8. Some LHDs will not be Advanced Medical Homes (AMHs)
Kathy

9. LHD Medicaid Services – Core Public Health
Partner with AMH in Managed Care
Where possible, close feedback and care loops with primary care medical homes. Maintain confidential services as required and indicated.
Core public health may include:
Family Planning
Communicable Disease/STD/TB
Immunizations
Pregnancy Testing
Prenatal Care
EPSDT Services
Diabetes and Nutrition Services
Family planning, Be Smart – carved out. But LHDs may provide family planning services to clients enrolled with a PHP in managed care. Carved in.

10. Some LHDs will be Advanced Medical Homes (AMHs)

11. Introduction to Advanced Medical Homes (AMH)
Vision for AMH in Managed Care
Build on the Carolina ACCESS program to preserve broad access to primary care services for Medicaid enrollees and strengthen the role of primary care in care management, care coordination, and quality improvement as the state transitions to managed care
Practices will have options under AMH:
Current Carolina ACCESS practices may continue into AMH with few changes; practices ready to take on more advanced care management functions may be eligible for additional payments
Practices may rely on in-house care management capacity or contract with a Clinically Integrated Network (CIN) or other partner of their choice
Unlike in Carolina ACCESS, practices WILL NOT be required to contract with any particular CIN to participate

12. AMH Tiers Tiers 1 and 2 Tier 3 Tier 4: To launch at a later date
PHP retains primary responsibility for care management
Practice requirements are the same as for Carolina ACCESS
Providers will need to coordinate across multiple plans: practices will need to interface with multiple PHPs, which will retain primary care management responsibility; PHPs may employ different approaches to care management
Per member per month (PMPM) Medical Home Payments
Same as Carolina ACCESS
Non-negotiable
AMH Payments
(paid by PHP to practice)
Tier 3
PMPM Medical Home Payments
Same as Carolina ACCESS
Non-negotiable
Additional Care Management Payments
Negotiated between PHP and practice
AMH Payments
(paid by PHP to practice)
PHP delegates primary responsibility for delivering care management to the practice level
Practice requirements: meet all Tier 1 and 2 requirements plus take on additional Tier 3 care management responsibilities
Single, consistent care management platform: Practices will have the option to provide care management in-house or through a single CIN/other partner across all Tier 3 PHP contracts
Tier 4: To launch at a later date

13. Contracting with CINs for AMH Support

14. What are CINs/Other Partners?
Practices that choose to work with CINs/other partners will have the freedom to choose any CIN that meets their unique needs
Types of Practices
Employed physician groups – employed directly by health system or faculty practice plan
Independent group practices – single or multi-specialty group practices, community clinics, and Federally Qualified Health Centers (FQHCs)
Local health departments (LHDs)
Practices must consider whether their in-house capabilities are sufficient to meet AMH Tier 3 requirements and how CINs/other partners may support them
Types of CINs
Hospitals, health systems, integrated delivery networks, Independent Practice Associations (IPAs) and other provider-based networks and associations
Care management organizations and technology vendors

15. How Can CINs/Other Partners Help AMHs?
CINs/other partners can offer a wide range of capabilities but practices will need to determine their precise gaps and needs
CINs/Other Partner Services May Include:
Providing local care coordination and care management functions and services
Supporting AMH data integration and analytics tasks from multiple PHPs and other sources, and providing actionable reports to AMH providers
Assisting in the contracting process on behalf of AMHs
Although the majority of AMH Tier 3 practices may elect to contract with CINs/other partners for support, practices are not required to do so
Some CIN contracts may include specific LHD arrangements. Check with the CIN to assure whether or not they will enforce those LHD specific contract requirements outside the AMH.

16. North Carolina’s Medicaid Transformation and Transition of Current Programs for High-Risk Pregnant Women and At-Risk Children
Beth

17. Payments to LHDs for CMHRP and CMARC
During the transition period, LHDs will be paid for care management services using the same payment amount and methodology that exists today.
Care Management Payments to LHDs
Per RFP: PHPs will compensate contracted LHDs at an amount similar to but no less than funding levels they receive today for these services
LHDs will be paid by PHPs for the provision of CMHRP and CMARC under managed care
LHDs will be paid the same amount and using the same methodology for the provision of these services
CMHRP: $4.96 PMPM for all PHP member women ages on Medicaid residing in the LHD county/service area
CMARC: $4.56 PMPM for all PHP member children ages 0-5 on Medicaid residing in the LHD county/service area
Funding related to care management for high-risk pregnancies and at-risk children is included in the capitation payment to PHPs*
Note: This presentation focuses on payments for care management services. Additional guidance on other payments (e.g. cost settlement) is forthcoming
*Funding for all IT expenses, including the care management documentation system and analytics platform, will be paid directly from DHB to CCNC and is not included in the payments from PHPs to LHDs. DHB and DPH are working to develop the contract terms as part of the transition to managed care.

18. Contracting with PHPs

19. State Oversight of LHD Contracts
PHP contracts with LHDs must contain standard contract terms; the State will produce standard contract language and clauses, but will not review contracts*
Payment Terms
Must provide sufficient detail regarding Medical Home Fees, Care Management Fees, and Performance Incentive Payments, as appropriate
Must adhere to payment floors as established by the State *(LHDs have UNIQUE payment methodology different than other types of primary care practices.)*
Other Requirements
Must be mutually agreeable
Must specify responsibilities of activities performed by an AMH vs. retained by the PHP
Must describe responsibilities for all required AMH tiers
Must specify reporting standards and performance monitoring in alignment with State standards
Must specify consequences for underperformance, including appeals rights
Must include data sharing and provisions for privacy/security, in alignment with the State’s data sharing policies
**PHPs should have appropriate contract terms for LHDs—separate and apart from AMHs contract terms.
In order to maintain level funding, every LHD will need to contract with every PHP serving their county.

20. Other key information
Kathy

21. Comparison – FFS vs. Managed Care
Fee-For-Service
Managed Care
NCTracks Paid Claims
Annual Cost Report Settlement
CPE for Non-Federal Share
Net LHD Payment is Federal Share of Cost Settlement
Annual Cost Report Reconciliation
Annual Cost Report Filing
PHP Paid Claims
Quarterly AUBP
IGT for Non-Federal Share
Net LHD Payment is Federal Share of AUBP
Annual Reconciliation of Managed Care Encounter Claims
Annual Cost Report Filing

22. Additional Utilization-Based Payments
Under Managed Care, and with CMS approval, LHDs will qualify for AUBP.
42 CFR § 438.6(c)(1)(iii)(B)
AUBPs for LHDs are based on provider specific Ratio of Costs to Charges (RCC).
AUBPs for LHDs are based on Medicaid and NCHC Claims paid by Prepaid Health Plans (PHPs).
AUBPs are in addition to base payments negotiated in contracts between PHPs and providers.
I have heard conflicting discussions about what the AUBP will be based on. I’ve heard it will be based on the PHP paid claims from the quarter prior and I’ve heard it will be based on a specific amount of the FY cost settlement. Can you please clarify?
The request for Additional Utilization Based Payments to Local Health Departments submitted to CMS for approval uses a Base Year Ratio of Cost to Charges (RCC) multiplied by Billed Charges that are shown on Paid Claims from the PHPs to the Health Departments.  The Base year is the 2017 Cost Report Data.  The intent is to have each PHP submit to the Division of Health Benefits a quarterly snapshot of claims they paid to the Health Department in the prior quarter.  It will be lagged by 45 days after the quarter.  For example, the claims paid by each PHP to the Health Department in the 4/1/2020 – 6/30/2020 period will be captured in a snapshot which is delivered to DHB by 8/15/2020.  The Billed Charges will be multiplied by the Base Year RCC to determine allowable payment.  The allowable payment is then indexed forward to the current period to account for inflation.  The actual payments received by the LHD from the PHPs are subtracted to determine the net allowable payment (very similar process to current cost report settlement).  The net result is the Additional Utilization based Payment.
What is the federal share of the AUBP? Can you explain more?
The AUBP is a whole dollar payment that is funded by a federal share and state share.  Currently in cost report settlements, the LHD net benefit is the federal share.  If the cost settlement calculated amount is $100 and the Federal Match rate is 65% then the LHD receives a cost settlement of $65.  In cost settlement, the state share (or 35% in this example) is satisfied by the Health Department certifying their expenditures.  Going forward into Managed Care with AUBPs, the funding mechanism changes, but the LHD receives the same net benefit.  For AUBPs, the state share will be satisfied by an intergovernmental transfer or IGT.  Continuing the same example, the LHD will be invoiced by the Division of Health Benefits for $35 (which is the state share).  The LHD will transfer this amount to DHB and DHB will direct the PHPs to pay the Health Department the full $100 (federal and state share combined).  The net benefit of $65 is the same to the LHD.
What percentage/amount will LHDs be responsible for transferring to initiate the AUBP each quarter?
The IGT amount will be calculated with each quarter.  It will be one invoice with data showing how the invoice was calculated, but it will be in aggregate.  The FMAP (Federal medical Assistance Percentage) on clinic services changes annually but is typically around 65% for North Carolina, Family Planning Services are 90%, and NC Health Choice Services are declining over the next several years from ~99% to ~70%.
Presuming we bill for all four PHPs in our region, we will have to initiate transfers for the AUBP with each PHP each quarter?
No.  The intent is for DHB to consolidate the calculation from all PHPs each quarter so the LHD receives only one invoice.  Continuing the above example, if the $100 AUBP is calculated from claims from four PHP’s, the LHD will receive one invoice for the state $35.  However, the LHD will then receive component payments from each PHP.  For example if each PHP had identical claims, then the LHD would receive $25 payment from each of the four PHPs to sum to $100.

23. Additional Utilization-Based Payments Cont.
AUBP’s
Calculated quarterly by PHPs for each LHD
Based on claims paid by each PHP to LHDs during that quarter
Paid quarterly, in aggregate, by the Division to each PHP
Upon receipt of aggregate AUBP, each PHP then remits to each LHD their respective AUBP

24. Advanced Medical Home Program
Quick Links
Advanced Medical Home Program
Behavioral Health I/DD Tailored Plans
Care Management
Provider Support
More InformationNC Medicaid Managed Care public notices, press releases, session laws and other general information
Submit a Comment
Feedback is welcome and encouraged
On the Medicaid Transformation website you will find these “quick links”. Provider support is where you will find the majority of the information you need, but please take a look at the others as time allows.
If you have attested to Tier II or III you will especially want to look at the Advanced Medical Home Program section. There you find the following map.

25. Additional Resources Policy Papers
Advanced Medical Home Website:
AMH Training Website and FAQs:
CMARC-CMHRP FAQs FINAL.pdf
Policy Papers
NC DHHS, “North Carolina’s Proposed Program Design for Medicaid Managed Care,” August 2017
NC DHHS, “North Carolina’s Care Management Strategy under Managed Care,” March 9, 2018
NC DHHS, “Data Strategy to Support the Advanced Medical Home Program in North Carolina,” July 20, 2018

26. Contacts
Beth Lovette, Acting Director Division of Public Health
Phyllis Rocco, Branch Head LTAT
Division of Public Health
Kathy Brooks, PH Administrative Consultant
Brook Johnson, PH Administrative Consultant
Lynn Conner, PHNPDU Nurse Consultant
Carolynn Hemric, PHNPDU Nurse Consultant
Rhonda Wright, PHNPDU Nurse Consultant
Pamela Langdon, PHNPDU Nurse Consultant
Susan Little, Manager, PHN, Admin & Financial Consultation, LTAT
We have compiled the contacts related to this presentation on this final slide for your reference. Please do not hesitate to reach out to your Administrative or Nurse Consultant for assistance or if you have additional questions about today. We are always happy to do all we can to assist you and your staff.
Thank you for your participation today. We hope you have found this information to be helpful.
Presenter Note: Leave this slide up and ask if there are any additional questions