Proposed Program Design

North Carolina has suspended the transition of Medicaid to managed care. Medicaid beneficiaries will get health services as they do now from the state. Beneficiaries do not need to choose a health plan. Behavioral health services will continue to be provided by Local Management Entities – Managed Care Organizations. All health providers enrolled in Medicaid are still part of the program and will continue to bill the state through NCTracks. Timelines noted within Medicaid Transformation policy papers, fact sheets and other communications will not apply.

Please call the Medicaid Contact Center at 888-245-0179 if you have questions.  

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Policy Papers and Final Policy Guidance

DHHS Medicaid Managed Care policy papers and final policy guidance documents focus on NC Medicaid Managed Care program features. 

Section 1115 Demonstration Waiver

On Oct. 24, 2018, the federal Centers for Medicare and Medicaid Services (CMS) approved North Carolina's 1115 Demonstration Waiver application submitted November 2017. The approval is effective Jan. 1, 2019 through Oct. 31, 2024. The amended waiver is the result of collaboration among DHHS, beneficiaries and their families, advocates, health care providers, health plans and associations, lawmakers and other stakeholders throughout North Carolina.

Section 1115 Demonstration Waiver Webcast - Oct. 26, 2018

Webcast Presentation

Webcast Transcript

NC 1115 Demonstration Waiver Fact Sheet

CMS 1115 Demonstration Waiver Approval Letter

NC 1115 Demonstration Waiver Press Release

NC Amended Section 1115 Demonstration Waiver Application - Nov. 20, 2017

Original NC Section 1115 Demonstration Waiver Application - June 1, 2016

Proposed NC Medicaid Managed Care Program Design

In August 2017, DHHS released a detailed proposed program design for transforming the state Medicaid and NC Health Choice programs to managed care. This proposed design document ensured that providers had an opportunity to review and comment on the specific of the DHHS vision for managed care prior to submitting the amended Section 1115 demonstration waiver application to CMS in November 2017.

Medicaid Managed Care Proposed Program Design - August 2017

Medicaid Managed Care Proposed Program Design Public Comment Summary - August/September 2017

Proposed Program Design Information for Beneficiaries and Providers

Below are key points of the proposed program design, specifically for providers or beneficiaries.

Medicaid Managed Care: A guide for people with North Carolina Medicaid - August 2017

Medicaid Managed Care: A guide for North Carolina Medicaid and NC Health Choice providers - August 2017

Provider Rate Floor and Reimbursement Scenarios

May 31, 2018–"Provider Rate Floor and Reimbursement Scenarios for North Carolina PHPs," prepared by DHHS, outlines reimbursement requirements for Prepaid Health Plans under various scenarios based on the interaction among rate floors, in-network service availability and a provider's in-network or out-of-network status in the context of North Carolina Medicaid managed care. The document addresses reimbursement for Medicaid covered benefits. Per member per month payment requirements for Advanced Medical Homes and care management functions are outside the scope of this document.

Public Hearings and Listening Sessions

DHHS knows it is crucial to listen to and learn from the people who live and work with Medicaid every day. To develop the strongest Medicaid program for North Carolina, DHHS continues to talk with providers, beneficiaries and advocates, health care experts across the state and the country, leaders in other states who have already transitioned Medicaid programs to managed care, and many others interested in improving the health of North Carolinians. DHHS is committed to continuing this partnership.

Medicaid Managed Care Public Comments Summary - April/May 2017 - Input from written comments and public listening sessions held by DHHS throughout the state