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Health Care
Jul 15, 2021

Six Years In The Making: Medicaid Transformation – It Happened!

Sponsored Content provided by Michealle Gady - Founder and President , Atromitos

On July 1st, North Carolina Medicaid Transformation officially launched. After 6 years of planning and a few starts and stops, we are finally off to the races. We are about two weeks into implementation and, as no one will be surprised to learn, we have encountered some hiccups. This cannot be avoided when you implement a change as significant as what the North Carolina Department of Health and Human Services (NC DHHS) has set out to achieve.
I will touch on three of the most significant challenges facing Medicaid enrollees and participating providers at this moment—Enrollment, Contracting, Continuity of Care—and provide insight and guidance on how Medicaid stakeholders can act to resolve these challenges. Because the foundational goal of the Medicaid program is to provide coverage to enrollees, let’s start by tackling the challenges related to enrollment.
Enrollment = PHP Assignment = Access to Primary Care Provider (PCP)
At the foundation of the transformation is the launch of managed care. This means that Medicaid and HealthChoice enrollees are now receiving their respective health benefits from a Prepaid Health Plan (PHP). To recap, there are five PHPs serving North Carolina:

  • Healthy Blue (statewide)
  • United Healthcare Community Plan (statewide)
  • AmeriHealth Caritas of North Carolina (statewide)
  • Wellcare of North Carolina (statewide)
  • Carolina Complete Health (Medicaid Regions 3, 4 and 5)
Enrollees had the chance to select a PHP and enroll in the plan of their choice. Not surprisingly, the vast majority of enrollees did not do so and were auto-enrolled in a PHP. This means that many enrollees do not actually know or understand that they have a different way of getting their health benefits. And not only is it important for enrollees to know their PHP assignment, but they also need to ensure that their Primary Care Provider (PCP) is contracted with or in-network with their assigned PHP and that the patient is assigned to that Provider as the PCP.
You may be wondering why this matters… as long as they are enrolled with a PHP won’t they continue to get services? While the answer is yes, there are complexities that muddy the water for both patients and providers (isn’t Medicaid fun!?!?). Below, I tease out the details and provide some simple steps to help providers and patients untangle this web.
Actions Providers Can Take to Resolve Enrollment Challenges
It is imperative that providers, especially primary care and behavioral health providers, communicate with their patients that they will need to bring their PHP identification (ID) card to their appointments. So, if you haven’t already, get the word out to your Medicaid panels that they should bring their new PHP ID card to their next appointment.
Providers can support patients by identifying which PHP the enrollee has through NC Tracks. When a provider searches for a patient in NC Tracks, it will identify one of two enrollments:
  1. the patient is enrolled with one of the five PHPs (shown as Managing Entity in NC Tracks) or
  2. the patient is enrolled in Medicaid Direct (traditional fee-for-service) and/or is enrolled with an LME-MCO for behavioral health coverage.
(Note: about 25% of the NC Medicaid population is not enrolled in managed care.)
With this information, the Provider can check eligibility and obtain needed information directly from the PHP, preventing any access delays and ensuring that the Provider can submit claims and receive payment for services.
Changing PHP Assignment

Providers cannot steer or direct enrollees to any particular PHP. However, providers can communicate with their patients which of the PHPs the provider has contracted with and therefore is in-network. It is important that patients know which PHPs their providers are contracted with so that they can determine if they need to change PHPs. Enrollees can change their PHP between now and September 29. After this point, they will only be able to change plans with cause until the next open enrollment period. Enrollees can change plans by contacting the Enrollment Broker at 1-833-870-5500.
Changing PCP Assignment

Primary Care Providers need to work with patients to ensure that the patient has been assigned by the PHP to Provider as the PCP. This has significant implications for Providers and Patients. Again, this can be checked in NC Tracks, in the PHP provider portal, and on the enrollees’ ID Card. Enrollees have until August 1, 2021 to change their assigned PCP without cause and will have up to one time per year after that point to make a change for any reason. After that, an enrollee needs cause to change their assigned PCP. To help a patient change their assigned PCP, call the PHP Member Services.
Provider Agreements = In-network = In-network Rates

We know from experience with our clients that the PHPs are still working through contracting with Providers. If you are not yet contracted with a PHP, don’t worry. For the first 60-days, all providers will be treated as if they are in-network and will be paid in-network rates. For newborns, this period is 90-days.
Actions Providers can Take to Resolve Contracting Challenges

If you are still waiting for your contract from a PHP, work directly with the contracting team at the PHP, but also know that you can and should share any concerns about the contracting process with the Medicaid Provider Ombudsman. At Atromitos, we have reached out to the Ombudsman on behalf of clients on more than one occasion and have found it to be highly effective.
When reaching out to the Ombudsman, be prepared by having your specific challenges documented. The more concrete and detailed you can be the better. The Ombudsman will need these details to help get resolution to your problems. Generic complaints are difficult to resolve.
Prior Authorizations (PA) = Needed Care = Provider Payment
For the first 90-days, prior authorizations that existed prior to go-live will remain in effect. For pharmacy prior authorizations, they remain in effect for one year after the original authorization. These existing prior authorizations should have transferred over to the PHPs. But, with all things data and information, that won’t happen 100% of the time. All of the PHPs have an electronic method for submitting prior authorizations. However, we know that some of the plans are experiencing problems with their portals.
Actions Providers can take to resolve PA Challenges

The PHPs know of the problems and are working to resolve them. In the event you have trouble submitting an electronic prior authorization request, call or fax (yep, we just went back to 1989) the PHP. Helpful numbers can be found in each PHPs Quick Reference Guide:
And again, document these ongoing challenges across your organization. Sharing trends you are seeing with the PHPs individually and the Ombudsman collectively will not only help resolve issues for your organization more quickly but may also lead to global changes and resolutions across the program for all patients and providers.
While these are the three most significant issues being experienced across the program, there are other issues everyone is working through, including:
  • Not all providers are contracted with all PHPs. There is a process for obtaining authorization for patients to continue to see out of network providers when that is in the best interest of the patient or another in-network provider is not available within the required time and distance standards. NC DHHS is aware that there is insufficient guidance available on this process and is working to remedy that.
  • Confusion about which benefits are covered by PHPs. We have encountered many questions about whether certain services are covered by PHPs or if a patient needs to go back to Medicaid Direct. The PHPs are required to cover all the federal mandatory and the North Carolina optional benefits provided in the fee-for-service program. (See pg. 2 of this resource.) PHPs also cover additional benefits called value added or in lieu of benefits. Check the PHPs Member Handbook or Provider Handbook for services. If you think that your patients are being denied coverage of services that they should have access to, please work with the respective PHP’s account representative assigned to your practice. If this is not successful, contact the Provider Ombudsman for support.
This will be an ongoing learning experience for everyone, including NC DHHS and the PHPs. Open communication among all parties will be critical to success. And let’s remember, that while we are working through issues, patients will be too. Providers need to be advocates for their patients and help them through this process as much as possible. This will require that providers stay apprised of developments in the program, because the one thing we can be certain of is that it will evolve with time.
Useful Resources:
Enrollment and Timelines
Provider Quick Reference Guide
Provider Update

Michealle Gady, JD, is Founder and President of Atromitos, LLC, a boutique consulting firm headquartered in Wilmington, North Carolina. Atromitos works with a variety of organizations from health payers and technology companies, to community-based organizations and nonprofits but their work reflects a singular mission: creating healthier, more resilient, and more equitable communities. Michealle takes nearly 20 years’ experience in health law and policy, program design and implementation, value-based care, and change management and puts it to work for Atromitos’ partners who are trying to succeed during this time of dramatic transformation within the U.S. healthcare system. Outside of leading the Atromitos team, Michealle serves as a Board Member for both the Cape Fear Literacy Council and A Safe Place and is a member of the American College of Healthcare Executives and American Health Law Association.

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