More Detail Released on Care Management in the Tailored Plans

NC DHHS has published a concept paper putting more detail into the concept of care management for those individuals who qualify for the Behavioral Health/Intellectual-Developmental Disability (BH/IDD) Tailored Plan.  Unlike the Standard Plan, every Medicaid beneficiary who is in a BH/IDD Tailored Plan will be assigned a care manager, with limited exceptions.  The care management service will be different than the current care coordination that Medicaid beneficiaries receive from the LME/MCOs, largely because it is expected to be integrated to include the physical healthcare, BH/IDD services, pharmacy and unmet health-related resources that an individual needs and will be provided closer to the individual. 

Care management is a fundamental component of North Carolina’s Medicaid Transformation and particularly in the Tailored Plans.  It is the service that will assist Medicaid beneficiaries to navigate their services and the system as a whole.  The service definition encompasses responsibilities that have been included in care coordination and case management in the past.  Care management is expected to be a multidisciplinary team-based approach with the Medicaid beneficiary will be at the center of the team.  The BH/IDD Tailored Plan is responsible for contracting with and paying for care management.  To support start-up for providers, NC DHHS has requested funding from the federal Centers for Medicare and Medicaid Services (CMS) to build the care management capacity in the public MH/IDD/SUD system.  NC DHHS has not yet received approval from CMS. 

Organizational Structure

NC DHHS has identified three different care management organizational structures:  

AMH+:  Those organizations that are attesting to be a Tier 3 Advanced Medical Home (AMH) under the Standard Plan may undergo NC DHHS’s certification process to become AMH+ organizations. 

Care Management Agency:  Providers of mental health, substance use disorder or intellectual-developmental disability services may apply to NC DHHS to be certified as a Care Management Agency. 

BH/IDD Tailored Plan:  The BH/IDD Tailored Plan itself may serve as the care management organization. 

Glide Path Provides a Transition to Care Management

The paper refers to a “Glide Path”.  The Glide Path is the term NC DHHS is using for the transition to the future care management service.   The goal for NC DHHS is to ensure that as many Medicaid beneficiaries in the BH/IDD Tailored Plans are receiving care management through an AMH+ or certified Care Management Agency as possible.  Each year, the BH/IDD Tailored Plan will be expected to have an increased percentage of their total Medicaid members who are either in an AMH+ or certified Care Management Agency and not receiving care management services by the Tailored Plan.  By July 2024, the expectation is that an AMH+ or certified Care Management Agency will be providing care management to 80% of the members of each Tailored Plan.  A Tailored Plan entity may provide this service because the member chooses them or because there is not an AMH+ or certified Care Management Agency near the member. 

The Glide Path also gives providers and LME/MCOs (the organizations that will become the Tailored Plan entities) time to organize for this service.  It allows LME/MCOs to transition their organizational structure to include staff who can be care managers and staff who can manage the service across their catchment area.  It gives provider agencies interested in care management time to hire and train staff and to receive agency certification (see Table 2, page 15).  During this transition, LME/MCOs will continue to provide the care coordination service that has been a part of the 1915(b)(c) Medicaid waiver and both Standard Plan and Tailored Plan entities will continue to provide care coordination under the 1115 waiver.

What Care Management Will Do for Medicaid Beneficiaries

As a part of the care management service, a Medicaid beneficiary will receive a comprehensive assessment of his/her needs through a multi-disciplinary team, with the beneficiary driving the process.  The team will develop a care plan that addresses the following:

• Physical health care needs
• Mental health needs
• Intellectual-Developmental Disability needs
• Substance use disorder needs
• Traumatic Brain Injury needs
• Long-term services and support needs
• Pharmacy needs
• Unmet health-related resource needs

On an ongoing basis, the care manager will:

• have a required number of contacts with the Medicaid beneficiary based on the level of needs of that individual (low, moderate, high);
• assist the Medicaid beneficiary when there is a transition of services.

Paying for the Service

• The rate will be higher than it is under the Standard Plan, and there will be tiers of rates to account for the higher acuity of needs;
• There will be potential for care managers to receive additional payments for their efforts in engaging Medicaid beneficiaries.

Next Steps

• NC DHHS plans to submit an amendment to CMS of the North Carolina Medicaid State Plan that will designate the BH/IDD Tailored Plan as the Health Home for Medicaid beneficiaries in the BH/IDD Tailored Plan.  This is important because it requires that the Health Home meet certain data-sharing expectations and there are quality measures to be met. 
• NC DHHS will establish the certification process for organizations that wish to become care management organizations under the BH/IDD Tailored Plan.  Note that a certification is not needed to be a Tier 3 Advanced Medical Home under the Standard Plan so this process is only applied to the Tailored Plans.  The certification process will include an evaluation of the separation of duties for providers to ensure that there is conflict-free care management being provided. 
• NC DHHS will evaluate and identify resolutions for any overlap of care management services where it is embedded in a service, e.g. Assertive Community Treatment Team. 

NC DHHS is asking for feedback on the care management concept up until June 28, 2019.  Comments can be submitted to Medicaid.Transformation@dhhs.nc.gov.