Care Management Strategy

North Carolina is preparing to transition its Medicaid and NC Health Choice programs to a managed care delivery system that will advance high-value care, improve population health, engage and support providers, and promote predictable and sustainable costs. In designing this transition, the goal of the Department of Health and Human Services (the Department) is to improve the health of North Carolinians through an innovative, person-centered and well-coordinated system of care that addresses medical and nonmedical drivers of health.

Care management is foundational to the success of North Carolina’s health care system for Medicaid enrollees, supporting high-quality delivery of the right care at the right place, and at the right time in the right setting. Under managed care, most Medicaid and Health Choice beneficiaries will enroll in prepaid health plans (PHP), integrated managed care products providing physical and behavioral health services, long-term services and supports, and pharmacy benefits. Populations not moving into managed care will continue to be served by the programs in the same manner as today.

The Department is committed to providing a pathway for a seamless transition of services for beneficiaries into the managed care environment and believes that the provision of care management services at the local level is the best approach.

Aligning with its broader goals for the transformation to Medicaid managed care, the Department has established the following guiding principles for its Medicaid care management strategy:

1. All Medicaid enrollees will have access to appropriate care management and coordination support across multiple settings of care, including a strong basis in primary care and connections to specialty care and community-based resources.

 2. Enrollees with high medical, behavioral or social needs should have access to a program of care management that includes the involvement of a multidisciplinary care team and the development of a written care plan.

3. Local care management—care management that is performed at the site of care, in the home or in the community where face-to-face interaction is possible—is the preferred approach, building on the strengths of the current care management structure.

4. Care managers will have access to timely and complete enrollee-level information.

 5. As part of care management and care coordination, enrollees will have access to direct linkages to programs and services that address unmet health-related resource needs affecting social determinants of health, along with follow-up and ongoing planning.

6. Care management activities will align with overall statewide priorities for achieving quality outcomes and value

The Department is eager to continue to engage with stakeholders as it refines its care management approach and begins operational planning. The Department expects that providers, potential PHPs, enrollees and advocacy groups will play an important role in this planning process to ensure a smooth, high-impact rollout of the care management strategy at managed care implementation. North Carolina will continue to plan its stakeholder engagement strategy for managed care launch.

Additional information located at: https://medicaid.ncdhhs.gov/care-management provides key information on how the transition of care management programs will occur over time into the State’s managed care model, how the programs will operate, and the expectations of providers, LHD’s, PHP’s and the Department in each.