NC Medicaid Managed Care

1 NC Medicaid North Carolina Medicaid Managed Care NC Medicaid 's Approved 1115 Demonstration Waiver The federal centers for medicare & Medicaid Services (CMS) approved North Carolina's 1115 waiver for a five-year demonstration period. The 1115 waiver provides the North Carolina Department of Health and Human Services (DHHS) important flexibility and federal authority to advance the well-being of North Carolinians and serves as a major milestone in implementing North Carolina's Medicaid transformation. VISION FOR Medicaid TRANSFORMATION NORTH CAROLINA'S 1115 WAIVER. DHHS is committed to improving the health Fundamentally, the waiver provides North Carolina and well-being of North Carolinians through with federal authority to implement Medicaid an innovative, whole-person centered and Managed care and phase certain populations into well-coordinated system of care that addresses Managed care over time.

2 Under the waiver, North both medical and non-medical drivers of health. Carolina has further federal authority to incorporate the following innovative features into its new BACKGROUND Managed care delivery system, further enhancing In 2015, the North Carolina General Assembly the program's ability to deliver on the state's enacted Session Law 2015-245, directing the transformational goals: transition of Medicaid from a predominantly fee-for- B ehavioral Health Integration, Tailored Plans and Specialized service structure to Managed care. In Managed care, Health Homes. This waiver approval supports DHHS will still be accountable for all aspects of the DHHS' broader goal to integrate behavioral Medicaid and NC Health Choice programs, but will health services, physical health services and delegate the direct management of certain health pharmacy benefits so that all Managed care services and financial risks to Prepaid Health Plans beneficiaries have seamless access to these (PHPs) that will contract with providers to deliver benefits through one insurance card.

3 DHHS. services for their members. received federal authority to provide a specific, Since 2015, DHHS has collaborated with and solicited more intensive set of behavioral health benefits extensive feedback on its transition to Managed care through Tailored Plans. Tailored Plans will serve from clinicians, hospitals, beneficiaries, counties, people with a serious mental illness, serious health plans, elected officials, advocates and other emotional disturbance, severe substance use stakeholders. Throughout this process, stakeholder disorder, intellectual/developmental disability feedback has shaped the program design. As a or a traumatic brain injury. North Carolina will result, DHHS has developed an innovative program also implement a specialized health home for Medicaid Managed care that is responsive to model to ensure strong care management for the needs of the beneficiaries it serves, as well as people in Tailored Plans.

4 Clinicians, hospitals and health plans. O pioid Strategy. To support broader state efforts In November 2017, North Carolina submitted an to combat the opioid crisis, DHHS received amended 1115 demonstration waiver application federal authority to increase access to inpatient to CMS that updated the waiver application and residential substance use disorder submitted in June 2016. The waiver application treatment through reimbursement for services focused only on those aspects of the broader in institutions of mental disease (IMD). This Medicaid Transformation effort that required federal authority will augment North Carolina's federal waiver authority from CMS (other features comprehensive strategy to improve care quality of transformation will be authorized through the and outcomes for patients with substance use state plan or contract approval processes).

5 Disorders, including efforts to decrease the 1. long-term use of opioids and increase the use of During waiver negotiations, CMS and North medication-assisted treatment (MAT) and other Carolina agreed to finalize a first set of activities treatment services. under the approved 1115 waiver authority while continuing to negotiate additional waiver and Healthy Opportunities Pilots. DHHS received CMS. expenditure authority requests over the upcoming approval to implement within Medicaid months. These open issues include: Managed care an innovative Healthy Opportunities pilot program in two to four U ncompensated Care Pool for Tribal Providers. North regions to improve health and reduce health Carolina's waiver application included a care costs. Recognizing that overall health is request for expenditure authority for an driven by many factors beyond the four walls uncompensated care pool to address the high of a hospital or clinic, these pilots, working with burden of uncompensated care borne by the the Managed care plans in their regions, will Cherokee Indian Hospital Authority (CIHA).

6 Identify the most cost-effective ways to deliver Uncompensated care refers to services care. The pilots will support and strengthen provided to patients who are unable to pay. work already underway in communities and Funds in uncompensated care pools go to at the state level to maximize efficiencies providers to help offset those losses. and effectiveness within the Managed care program, focusing on housing, food, W. orkforce. North Carolina proposed to invest transportation, employment and interpersonal in building its Medicaid provider network safety. North Carolina is the first state to through an Innovation Workforce Fund. The receive approval to comprehensively pilot Fund would support loan repayment and these innovations, making it a national leader in recruitment bonuses for critical Medicaid promoting value and improving health through provider types targeted to fill identified gaps its Managed care program.

7 In the Medicaid provider network. E valuation. As is standard practice for 1115 B ehavioral Health Home Capacity-Building Funds. DHHS. waivers, North Carolina will arrange is working with CMS to gain approval for for a third-party entity to conduct an providing capacity-building funds to support independent evaluation of this demonstration the development of a strong health home to understand the extent to which the care management model to meet the needs demonstration has meaningfully improved of people with I/DD or significant behavioral health and maximized high-value care, among health needs. other goals. North Carolina will submit to CMS. For more information on North Carolina's two publicly available reports prepared by the approved waiver or more information about independent evaluator: one in the middle of Medicaid Managed care, visit the Medicaid the demonstration and one after the five-year Transformation website at demonstration period (2019-2024) ends.

8 Medicaid -transformation. B udget Neutrality. CMS policy requires that 1115. waiver demonstrations be budget neutral to the federal government, meaning that North Carolina not spend more than it projected to spend without the waiver. North Carolina submitted projected spending with and without the waiver, demonstrating that federal expenditures are not expected to be higher under the waiver. State of North Carolina Department of Health and Human Services Division of Health Benefits (NC Medicaid ). NCDHHS is an equal opportunity employer and provider. 10/2018.