Here's how North Carolinians will be affected by proposed Medicaid changes - eventually

When it comes to Medicaid transformation in North Carolina in 2020, some people may be wondering when it will happen.

North Carolina's transformation of its Medicaid program aims to deliver physical and behavioral health services in a more integrated and cost-effective way through new Standard Plans and Tailored Plans. Instead of paying for each healthcare visit or service individually, it would instead pay a set rate for the administration of beneficiary services.

North Carolina's Local Management Entities/Managed Care Organizations (LME-MCOs), like Alliance Health, have been operating under a managed-care model since 2013, and are planning to transition to operating a Tailored Plan under Medicaid transformation.

Tailored Plans will ensure comprehensive, whole-person care for people with severe mental illnesses, substance use disorders and long-term care needs, including intellectual/developmental disabilities and traumatic brain injuries. Beneficiaries would have all of their care – physical and behavioral healthcare, and pharmacy services – managed by a single health plan.

Standard Plans would provide comprehensive care – physical and behavioral healthcare, as well as pharmacy services – for most North Carolina beneficiaries, including those with mild-to-moderate behavioral health issues.

However, this managed-care implementation and open enrollment for Medicaid health plans have been suspended for now due to the continuing state budget stalemate.

For now, Medicaid will continue to operate under the current fee-for-service model used by physical healthcare providers, and the managed-care model employed by the behavioral health managed care organizations.

"Nothing will change for Medicaid beneficiaries – they will get health services as they do today. Behavioral health services will continue to be provided by the LME-MCOs. All health providers enrolled in Medicaid are still part of the program and will continue to bill the state through NCTracks," the statement continued.

"Let's say you're on Medicaid and need a behavioral health service. That service is managed by an organization like us, the LME-MCO," Doug Fuller, communications director at Alliance Health. "Until Medicaid transformation goes live and integrates behavioral and physical healthcare services, you must get your physical healthcare from somewhere else."

Fuller continued, "While LME-MCOs already receive a lump sum to oversee behavioral health outcomes for each beneficiary, your physical healthcare services are paid for by the state on a fee-for-service basis. If you get some X-rays and treatment for a broken arm, for example, your doctor bills the state for each service. With managed care, the federal government pays the health plan X amount of dollars per month for every Medicaid-eligible individual in its coverage area.

"MCOs hold the financial risk associated with the health of their members, and are incentivized to use resources wisely and improve health outcomes."

Rob Robinson, CEO of Alliance Health, added that the "LME-MCO public managed care system has been successful in achieving the mandate of the North Carolina's General Assembly and the Department of Health and Human Services to obtain Medicaid budget predictability and gain control over rising healthcare costs."

"Since the implementation of managed care, the LME-MCOs have met their legislative directives, not possible under a fee-for-service model, through active consumer education and outreach, effective care management, and development of innovative, evidence-based services," he said. "Alliance is a strong supporter of the DHHS direction for transitioning the entire public healthcare system to managed care."

Things to Know Now About N.C. Medicaid Transformation

He added, "We believe this transformation to managed care across the board is the most effective way to ensure that all citizens served by our state's public system receive the comprehensive, whole-person care they deserve."