Transition of Care Further Explained

If you are a consumer or family member, perhaps the most important aspect of this transformation is assurances that moves between plans, providers and emergency services will not be disruptive.  The Transition of Care policy that NC DHHS has published covers the responsibilities of the Prepaid Health Plans (PHPs) in these circumstances:

• when a Medicaid beneficiary disenrolls from a PHP Standard Plan, which could be because the beneficiary moves to another PHP or to the LME/MCO (later to be the BH/IDD Tailored Plan) and Medicaid Direct (fee-for-service primary care until Tailored Plans launch in 2022);
• when a Medicaid beneficiary changes providers;
• need for transitional care management.

There are two distinct phases of transition of care.  As the State moves to the Standard Plans on July 1 and Medicaid beneficiaries begin to be served under PHPs, that sets in motion the initial phase of crossover.  The second phase will be the ongoing transitional needs of Standard Plan members.  A key part of transition of care is the sharing of data such as authorization information and care plans.  There are several documents that are a part of the data guidance requirements. 

It is important to note that:

• Prior authorizations that Medicaid beneficiaries have received before the beginning of the Standard Plan will remain in place for up to 90 days or when the authorization was set to expire;
• Out of network providers will be treated the same as in-network providers for the first 60 days after the start of the Standard Plans;
• A Medicaid beneficiaries unmanaged visit count will restart when they begin with the Standard Plan;
• PHPs will begin accepting scheduling requests for Non-Emergent Medical Transport (NEMT) as of June 1, 2021. 

The i2i Center for Integrative Health 2021 virtual Spring Conference on June 14-15 will include several sessions related to Medicaid Transformation.  In fact, the closing plenary session will be an update from NC DHHS Deputy Secretary of Medicaid Dave Richard.