This document discusses North Carolina's transition to Medicaid managed care and efforts to address behavioral health challenges. It summarizes NC's behavioral health strategic plan which aims to provide timely access to integrated behavioral and physical health services. It also discusses closing the Medicaid coverage gap, the goals of Medicaid transformation including whole-person focused care and supporting providers. Tailored Medicaid plans are outlined to serve members with significant behavioral health and intellectual/developmental disability needs.

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NC Department of Health and Human Services
Transitioning to Medicaid
Managed Care
Mandy Cohen, MD, MPH
Secretary, NC Department of Health
and Human Services
January 14, 2019

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NC Behavioral Health Challenges
• Chronically underfunded mental healthcare system
• 13.6 % of people in NC are uninsured
• 56% of adults with mental illness don’t receive treatment
• Stigma
• Lack of practicing BH workforce
• Imbalance of community-based services relative to
inpatient and residential care
• ED boarding
• Insufficient community-based resources
• NC ranks 30th in US in ACEs prevalence
• Opioid Crisis – straining an already stretched
behavioral health system

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Behavioral Health
Strategic Plan

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BH Strategic Plan Recommendations
1. Timely access to high-quality services
• Close the coverage gap
• Develop community-based services that match
existing needs
• Monitor the balance of in-patient beds and
home and community-based services
• Strengthen community collaboration to
develop, assess, and improve services
• State operated healthcare facilities will
continue to provide and develop integrated
high-quality safety net services

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BH Strategic Plan Recommendations
2. Integrated Behavioral Health, I/DD, and
Physical Health Services
• One insurance card
‒ Medicaid Managed Care: Standard Plans and Tailored
Plans
• Routine screening for children and adults
• Robust communication practices between
behavioral and physical health providers
• Improve data and measurement to drive
accountability and encourage innovation

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Closing the Coverage Gap

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Expanding Medicaid and closing the coverage
gap increases access to affordable health care
• NC ranks 46th in the nation for the share of low-
income adults who forgo care due to cost
• NC ranks 42nd in the nation for the share of people
without health insurance 13.6%
• Lack of insurance disproportionately affects rural
communities
− 19% of rural North Carolinians lack health insurance
• 82% of rural hospital closures in the US have been
in states that have NOT closed the gap

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Closing the Coverage Gap
500,000 New projected enrollees due to expansion, including
a disproportionate number of rural North Carolinians
43,000+
Jobs created in the first five years of expanding
Medicaid, including the 44 rural counties where a
hospital is a top employer
$4 billion Annual federal dollars NC leaves on the table by not
closing the coverage gap
90% Share of costs paid by the federal government
$0 New state appropriation needed to fund the
expansion
up to 150,000 Currently uninsured North Carolinians with opioid/
other behavioral health needs who could enroll

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Medicaid Transformation

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Medicaid Transformation Goals
• Transforming from state run Medicaid program
to a managed care administered system
• Using best practices from other states and
building on the existing infrastructure in NC
1. Whole-Person Focused
2. Support Clinicians and Beneficiaries in the
Transition
3. Promote Access to Care
4. Promote Quality and Value

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Whole Person Focused: Behavioral Health Integration
• Standard Plans – 1.6 Million beneficiaries (moms
and kids)
−4 statewide PHPs, up to 12 regional
− Award in February 2019
−“Primary care” behavioral health spend included in PHP
capitation rate
−Phase 1 November 2019; Phase 2 February 2020
−PHPs must include all willing providers in networks
• Tailored Plans – Delayed start, July 2021
−Specialized managed care plans targeted toward populations
with significant BH and I/DD needs
−Access to expanded service array
−Behavioral Health Homes

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Benefits and Coverage
• PHPs are required to cover all benefits that would
otherwise be covered in FFS
• PHPs cannot impose more stringent benefit limits
• PHPs may design their own clinical coverage policies
− DHHS policy paper identifies small # of services where DHHS
policies will be required
• PHPs will use standard prior authorization forms to
minimize provider burden
• PHPs will use DHHS prescription drug list and drug
coverage criteria

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Supporting Providers through Transition
• Rate floor: 100% of Medicaid fee-for-service rate
• Ease provider administrative burden:
‒ Standardizing and simplifying admin processes and standards
• Standardizing quality measures across PHPs
• Standard contract forms, standard Prior Auth forms
• DHHS definition of “medical necessity” for coverage decisions
‒ Incorporating a centralized, streamlined provider enrollment and
credentialing process
‒ Establishing a single statewide drug formulary that all PHPs will be
required to utilize
‒ Requiring PHPs to cover the same services as Medicaid fee-for-
service
‒ Ensuring transparent and fair payments for PHPs and providers

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Promoting Quality, Value and Population Health
• Statewide Quality Strategy
‒PHPs will be monitored on 33 quality measures against national
benchmarks and state targets
• Advanced Medical Homes
‒4 tiers of participation, with practice requirements, payment models
and performance incentive payment expectations differing by tier.
‒Sophisticated data capabilities needed across the state, the plans,
and the practices/CINs
• Value-Based Payment
‒By the end of Year 2 of PHP operations, the portion of each PHP’s
medical expenditures governed under VBP arrangements will either:
• Increase by 20 percentage points, or
• Represent at least 50% of total medical expenditures.

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Tailored Plans

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Key Features of Tailored Plans
• TP contracts will be regional, not statewide
• LME-MCOs are the only entities that may hold a TP
contract during the first four years
• LME-MCOs operating TPs must contract with an entity
that holds a PHP license and covers the same services
as under a standard benefit plan contract
• Individuals will be identified for TP enrollment through
either DHHS data review or self-identification
• DHHS needs to define 5-7 regions

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Behavioral Health and I/DD Services Available in
Standard Plans and Tailored Plans
Covered by both Standard and Tailored Plans Covered exclusively by Tailored Plans
State Plan BH and I/DD Services
 Inpatient behavioral health services
 Outpatient behavioral health emergency room services
 Outpatient behavioral health services provided by
direct-enrolled providers
 Partial hospitalization
 Mobile crisis management
 Substance abuse intensive outpatient program (SAIOP)
 Facility-based crisis services for children and
adolescents
 Professional treatment services in facility-based crisis
program
 Psychosocial rehabilitation
 Outpatient opioid treatment
 Ambulatory detoxification
 Non-hospital medical detoxification
 Medically supervised or alcohol drug abuse treatment
center (ADATC) detoxification crisis stabilization
 Substance abuse comprehensive outpatient treatment
program (SACOT)
 Research-Based Behavioral Health Treatment of Autism
Spectrum Disorder (pending CMS approval)
 Diagnostic assessments
EPSDT
State Plan BH and I/DD Services
 Residential treatment facility services
 Child and adolescent day treatment services
 Intensive in-home services
 Multi-systemic therapy services
 Psychiatric residential treatment facilities (PRTFs)
 Assertive community treatment (ACT)
 Community support team (CST)
 Substance use non-medical community residential
treatment
 Substance abuse medically monitored residential
treatment
 Intermediate care facilities for individuals with
intellectual disabilities (ICF/IID)
 Diagnostic assessments
Waiver Services
 TBI waiver services
 Innovations waiver services
 1915(b)(3) services
All State-Funded BH and I/DD Services
State-Funded TBI Services
EPSDT

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Care Management in Tailored Plans:
Behavioral Health Homes
• All BH I/DD TP enrollees will be eligible for care
management
• Every enrollee will have a single assigned care
manager responsible for ensuring integrated and
coordinated services
• BH I/DD TP care management will be available for
longer periods of time and with a greater focus on
transitions of care than care coordination currently
offered by LME-MCOs
• Care management will be community-based to the
maximum extent possible

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Investing in Health Opportunities
• Statewide standardized screening
questions
• Required for Managed Care Plans
Screening
Questions
• Connect patients to community resources
through a Statewide Resource Database
• Referral Platform
Resource
Platform
• Test non-medical interventions to improve health
and reduce costs
• $650 million through 1115 Waiver (CMS approved)
Regional
Pilots

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Healthy Opportunities Pilots
Timeline: 5-year pilot, Regions selected late 2019, rollout late 2020
Eligibility: Participants must be enrolled in NC Medicaid, have at least
one physical/behavioral health risk factor & at least one social risk
factor
Tracking Outcomes: features included to ensure accountability
• Evaluation – rapid-cycle assessments to track health outcomes
and costs
• Course correction – shifting pilot dollars to most effective
interventions
• Paying for value – payments for pilot services will increasingly
be linked to health outcomes
$650 million in Medicaid expenditure authority for regional pilots to test
interventions addressing housing, food transportation, interpersonal
violence, toxic stress for eligible Medicaid enrollees to improve health.*

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Addressing the Opioid Crisis

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Opioid Overdose ED visits
2021 Q4 expected
ED visits based on
2013-2016 trend
Actual ED visits
GOAL
ICD-9-CM ICD-10-CM
NC Opioid Action
Plan Starts
*Data are preliminary and subject to change
Source: NC Division of Public Health, Epidemiology Section, NC DETECT, 2009-2018 Q2
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000

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Opioid Strategy
• CMS recently approved opioid strategy as part of
our 1115 waiver
• Federal authority to reimburse for substance use
disorder services provided in institutions of mental
disease (IMDs)
‒Increases access to Medicaid-supported substance use
disorder treatment/services in inpatient settings above 15
individuals
• Expanded substance use disorder service array
‒Goal: increasing the use of medication-assisted treatment
(MAT) and other opioid treatment services

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Questions?
@SecMandyCohen