Top Benefits, Challenges of NC Medicaid Managed Care Model

Medicaid managed care enables care coordination, incorporation of social determinants of health into care, trust-building between healthcare stakeholders, stakeholder accountability, and flexibility for Medicaid beneficiaries, according to a report from North Carolina for Better Medicaid (NCBM).

NCBM, a multi-stakeholder group that supports Medicaid managed care, explored the results of North Carolina’s transition from fee-for-service Medicaid to a Medicaid managed care model.  The organization interviewed advocates, care managers, and other stakeholders with proximity to or involvement in the model.

“This report reflects important feedback on Medicaid Managed Care in North Carolina from key stakeholders who have direct experience with the transition,” Kathleen Nolan, regional vice president at Health Management Associates (HMA), said in the press release. “These early experiences can help inform opportunities for the program as implementation continues.”

North Carolina’s Medicaid managed care format relies on care management. The care management team incorporates registered nurses, community health workers, behavioral healthcare specialists, and others. 

As a result of bringing these different stakeholders together, Medicaid beneficiaries experience care that integrates behavioral and mental healthcare into physical care and that prioritizes addressing social determinants of health.

Eight out of ten beneficiaries enrolled in an advanced medical home practice designed for integrated physical and behavioral healthcare.

“While we are less than a year into the transition, MMC's emphasis on whole-person care is already providing us with opportunities to address the social determinants of health that so often go overlooked in the health care system,” said Sheree Vodicka, a member of NCBM and chief executive officer for the North Carolina Alliance of YMCAs.

The model also uses an Advanced Medical Home Tier 3 (AMH3) program to allow beneficiaries to access a multidisciplinary care team through their primary care providers. 

Health plans that managed care in North Carolina’s Medicaid program leveraged community health workers with extensive local knowledge and various supports such as housing specialists to connect beneficiaries to the right community resources. They also armed these workers with tools like referral resource management platforms.

In addition to these resources and referrals, the managed care organization introduced value-added benefits—which address health-related social determinants of health—and in-lieu-of services—which cover medically-appropriate procedures or sites of care that are generally not covered through Medicaid. 

North Carolina’s in-lieu-of services require that prepaid health plans allow beneficiaries to replace acute psychiatric care or substance abuse care with Institute for Mental Disease. Plans also must offer certain types of behavioral healthcare such as outpatient plus, home healthcare pediatric therapy for substance abuse or mental healthcare needs, and rapid care services.

Value-added benefits included medical benefits such as breastfeeding kits, over-the-counter medication allowances, and chronic pain management support. Health-related non-medical value-added benefits included food insecurity and meal supports, cellphone and carrier plan options, and youth club memberships.

The report found that these benefits offered beneficiaries more choice in how they approached their healthcare. Patient advocates found that quality of care was higher due to competition between health plans to produce the best benefits.

Beneficiaries were not the only stakeholders to benefit from the shift. Most providers reported a positive experience with the managed care program, with 50 to 70 percent stating that their experience so far with the managed care program was “good” or “excellent.”

“Our early experience with Medicaid Managed Care shows just how positive it can be for beneficiaries and those who serve them,” Vodicka said.

Although the North Carolina Medicaid managed care model received much positive feedback from the stakeholders that NCBM interviewed, the responses also indicated room for improvement.

Some beneficiaries found that their Medicaid plan choices were limited by which health plans covered their providers since providers do not have to contract with all Medicaid managed care plans. 

Families with children who have special health care needs were particularly restricted by this dilemma. Patient advocates found that families had trouble assessing what plans covered their providers.

Additionally, the advocates urged improving the Medicaid program’s communications with beneficiaries. In particular, the advocates cited the confusing communications around the transition, stating that up to 7,500 beneficiaries who should have been in carved out fee-for-service plans enrolled in standard managed care plans instead.

The English communications were confusing, and the translated communications were worse, with the Spanish translation of Medicaid communications being particularly garbled. Experts noted that strong stakeholder communication was essential for this transition to be successful.

Providers reported that missing codes were responsible for issues with claim denials, and they called on the Medicaid program to standardize administrative processes to reduce the burden.

“A story emerging from North Carolina’s transition to managed care is the critical importance of local knowledge and local engagement to support member health and member needs,” the report concluded. “Health advocates and CHWs agree — local knowledge and approaches to member and provider resource identification and engagement engender trust between members, providers, and the health plan.”

NCBM’s report urged the Medicaid program to improve trust with beneficiaries, build off of the community connections made during the coronavirus pandemic to create a permanent network, and continue to find more public health champions.

North Carolina announced its Medicaid transformation program in 2020 after sidestepping Medicaid expansion.