North Carolina MEDICAID TRANSFORMATION Update for Local Public Health Departments

1. North CarolinaMEDICAID TRANSFORMATIONUpdate for Local Public Health Departments https://www.ncdhhs.gov/assistance/medicaid-transformation

2. North Carolina’s Vision forMedicaid 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.” MEDICAID MANAGED CARE WEBCAST | July 15, 2019

3. Region 4 Feb 2020 Region 2 Feb 2020 Region 6 Feb 2020 Region 1 Feb 2020 Region 3 Feb 2020 PLE Region 5 Feb 2020

4. What and who are included in managed care?

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 Post-Transformation: Managed Care Pre-Transformation: (now called) NC Medicaid Direct • Medicaid Provider – All LHDs • Medicaid Provider – All LHDs • Advanced Medical Home • Carolina ACCESS • Pregnancy Management Program (PMP) • Pregnancy Medical Home • Care Coordination for Children (CC4C) • Care Management for At-Risk Children (CMARC) • Obstetric Care Management (OBCM) • Care Management for High-Risk Pregnancy (CMHRP) • Note: These programswill remain in place post-transformationfor 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)

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

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 • 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 Tier 3 • 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 • 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) • Per member per month (PMPM) Medical Home Payments • Same as Carolina ACCESS • Non-negotiable AMH Payments (paid by PHP to practice) 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

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

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 14-44 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.

20. Other key information

21. Comparison – FFS vs. 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 • Fee-For-Service • Managed Care • 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.

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. Quick Links

25. Additional Resources • Advanced Medical Home Website: https://medicaid.ncdhhs.gov/advanced-medical-home • AMH Training Website and FAQs:https://medicaid.ncdhhs.gov/amh-training • CMARC-CMHRP FAQs https://files.nc.gov/ncdma/Frequently-Asked-Questions-CMARC-CMHRP-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