Transition of Care Across Medicaid Plans Detailed in Concept Paper

Every day, people move from one insurance company to another and from one medical professional to another.  NC DHHS has published a draft concept paper that lays out more detail on how Medicaid beneficiaries can move from one payer or provider to another while their continuity of care is maintained during the initial implementation of the Standard Plans and ongoing.  As noted on the February 18^th webinar about the concept paper, transitions of care will happen often.  The “guardrails” that NC DHHS places around transitions within this concept paper are really to focus on those Medicaid beneficiaries in the Standard Plans with high needs.  It’s a reasonable assumption that the BH/IDD Tailored Plans will also have requirements to uphold around transitions of care. 

The transitions within Medicaid managed care that are discussed include:

Moving from Standard Plan A → to Standard Plan B

Moving from Standard Plan → to NC Medicaid Direct/LME-MCO (until the BH/IDD Tailored Plan is implemented)

Moving from Provider A → to Provider B with the Standard Plan oversight responsibility of that shift (spoiler alert—it happens through Transitional Care Management)

Some transitions will also take Medicaid beneficiaries out of managed care because they require services that are not yet included in Medicaid managed care and NC DHHS expects for there to be a seamless shift for these beneficiaries as well.  Those circumstances include:  

• Individuals becoming eligible for Medicare and, therefore, being “dually eligible”.
• Children and youth moving into the NC Foster Care System.
• Adults moving to a skilled nursing facility for more than 90 days.

For Medicaid beneficiaries, there are some safeguards incorporated into the Standard Plan requirements for any transition. 

• When a member is admitted to an inpatient setting and it becomes clear that individual will transfer to the BH/IDD Tailored Plan, the Standard Plan will cover the cost of inpatient care until discharge occurs.
• The Medicaid beneficiary will be held harmless for the cost of any medically necessary covered services even during a transition.
• The existing authorization period for a service will be honored regardless of a transition from one plan to another. 
• The Medicaid beneficiary will be notified if a provider they use is terminated from the Standard Plan network. 
• If a provider is no longer within the Standard Plan network, the Medicaid beneficiary will receive assistance to transition to another in-network provider.
• A Medicaid beneficiary in a Standard Plan can expect to be educated on their rights and the processes for maintaining services during the transition to another plan.

The majority of responsibility for ensuring the seamless transition resides with the Standard Plan in which the Medicaid beneficiary is currently a member.  They will include contractual provisions with their partners to carry out those responsibilities.  A key partner is the Tier 3 Advanced Medical Home.  These entities will certify that they can provide transitional care management.  That is the main tool that will be used to ensure that a Medicaid beneficiary has the supports and information needed to make a shift in plans or providers. 

The Standard Plan responsibilities include process-oriented requirements related to the transfer of the beneficiary’s files to the receiving Plan.  Data that needs to be share will be:  current care needs screening, current authorized services, open adverse determination information (appeals), current care plan, current comprehensive assessment, medication list, active diagnoses, known allergies and upcoming appointments.

Transition requirements also include the “warm hand-off” approach that should minimize unplanned or unnecessary readmissions, emergency department visits, or adverse outcomes. Standard Plans are expected to “develop a methodology for identifying Members who are at risk of readmissions and other poor outcomes.”  The methodology will include information such as use of high-level services and the Medicaid beneficiary’s current physical, BH/IDD, medication and unrelated health needs.  Medicaid beneficiaries who are identified through this methodology will be targeted to receive transitional care management as needed. 

Comments and feedback on the paper were due by March 6^th.