NC Medicaid is getting a complete overhaul. Politically, everyone is lost and has no idea how this will work. Back in 2010-ish, when NC went to the MCO model, which we have now, hundreds of providers were not paid or had trouble getting paid until the “dust” settled, and the MCOs were familiar with their jobs. Providers continue to suffer nonpayment from MCOs.

The new model consists of two, separate models: (1) the Standard Plan; and (2) the Tailored Plan models.

What’s the difference?

The Tailored Plan

Applies to:

  • People who get Innovations Waiver services
  • People who get Traumatic Brain Injury (TBI) Waiver services
  • People who may have a mental health disorder,substance use disorder, intellectual /developmental disability (I/DD) or traumatic brain injury (TBI).

The Standard Plan

Applies to everyone else. It is normal, physical Medicaid.

December 1, 2022, is the “go-live” date for the Tailored Plans.

Unlike the MCO model, the Tailored Plan offers physical health, pharmacy, care management and behavioral health services. It is for members who may have significant mental health needs, severe substance use disorders, intellectual/developmental disabilities (I/DDs) or traumatic brain injuries (TBIs). Tailored Plans offer added services for members who qualify. DHHS is trying to distance itself from any Medicaid administration by hiring all these private companies to manage Medicaid for DHHS. DHHS has to get federal Waivers to do this.

The MCOs are taking on a new function. Starting December 1, 2022, the MCOs will be managing physical care, as well as mental health and substance abuse.

I see this HUGE change as good and bad (isn’t everything?). The good side effect of this transition is that Medicaid recipients who suffer mental health and/or substance abuse will have their physical health taken care of by the same MCO that manage their mental health and/or substance abuse services. Despite, this positive side effect, we all know that whenever NC Medicaid is OVERHAULED, consumers fall between cracks on a large scale. Let’s just hope that this transition will be easier than past transitions.

Dave Richard, Deputy Secretary NC Medicaid, NCDHHS, gave a presentation today for the NCSHCA. He said that the transition to MCOs was rocky. What does he think will happen when we transfer to the Tailored Plan?

I think I may ask him whether he thinks whether the MCOs are doing a good job, presently.

He’s a great presenter.

He said that the hospitals have come together in the last 4 weeks. He said that we will see something in the media on Monday.

He wants to expand Medicaid because his agency DHHS would be awarded $1.5 Billion over the course of 2 years. Of course, he wants to expand. He has no idea that the MCOs are “terminating at will” providers within the catchment areas in a disproportionate and discriminatory way.

We are close to expansion, he said. 80%, he guessed. “Expansion is really important.”

Not if there are not enough providers.

I did not ask him my question.

Today Mr. Richard had to get a bunch of data from the “new plans.” We are 2 1/2 months away, and he said they are not prepared yet, but hopes to be prepared by December 1, 2022. They still have the discretion to “pull the plug.” He’s worried about a lot of providers who have invested a lot of money to get compliant and ready for the transformation – that they won’t get paid.

“We have 5 really, strong Standard Plans,” he said. Most Medicaid recipients will choose the 5 Standard Plans,

Attorney from the audience: “We have to raise reimbursement rates.” There is a staffing crisis, the attorney, emphasized.

Mr. Richard stated that there will be a raise, but no indication of how much.

Finally, I did ask him his opinion as to whether he thinks the MCOs are doing better now than when the transformation happened (back in 2010-ish).

He said, that nothing is perfect. And that other Medicaid Deputy Secretaries think very highly of NC’s program. I wonder if he’ll run for office. He would win.

The guy next to me asked, “What is the future of the Tailored Plans when they go out of business in 4 years?”

Mr. Richards said that there needed to be competition for being the “big dogs.”

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on September 16, 2022, in "Single State Agency", Access to Care, Alliance, Behavioral health, Hospitals, Knicole Emanuel, Legislation, Managed Care, Medicaid, Medicaid Advocate, Medicaid Attorney, Medicaid Providers, Medicaid Recipients, Medicaid Reform, Medicaid Reimbursements, Medicaid Services, Medicaid Spending, Medicare, Medicare and Medicaid Provider Audits, Medicare Attorney, Mental Health, Mental Health Problems, NC DHHS, North Carolina, Roy Cooper, Trillium and tagged , , , , , , , , , , , , , . Bookmark the permalink. 3 Comments.

  1. The tailored plan is not ready to take on the most needy individuals. The medically fragile need a program to meet their needs. This program is tailored for the mental health population.

    We can not find our PCP, we do not have access to Case Managers except for the ARC and they can not do the whole state. We are told we can just stay with our current case manager. Are they credentialed? Have they had any training to meet the physical health of the very medically needy? The MCO’s and this State are not looking at the whole picture of what it takes to take care of an individual with multiple complex issues.

    Who is trained in the needs of the IDD population? Who is trained in the care of Tramatic Brain Injury population? Who is trained in the care of the Medically Fragile at the MCO?

    I can see a freight train towards disaster. The MCO does not realize the steps necessary to meet the needs of an individual who needs procedures done. It is not just get PCP. There are multiple steps in many medical procedures that these individuals need and many providers who need to be contracted to meet their needs.

    Not all these individuals are associated with the hospitals. Why since we are supposed to sign up are many of the hospitals not on board? This last minute of a big announcement about the hospitals is a little late to begin to roll this out December1.

    Everything points to a big WE ARE NOT READY.

    Can anyone help we individuals who fall into this catagory?

  2. The 5 PHPs were building (and still are) the plane as is was taking off July 2021. Despite the turbulence, I do feel there are some excellent care management programs in place and the PHPs are actively engaging in improvements on the care provision side. As for timely payments and accurate reimbursements, there is still a large gap. I have no doubt TP will be similar but I am hoping lessons learned from the last launch will benefit these patients.

Leave a Reply

%d bloggers like this: