Medicaid Managed Care Contracts Awarded

By Chad Stage

After a long and competitive Request for Proposal (RFP) process, on Monday, February 4, 2019 the North Carolina Department of Health and Human Services (NCDHHS) announced awards to four statewide and one regional Prepaid Health Plans (PHP) that will administer the NC Medicaid and Health Choice programs.

The transformation of the current system will occur in a staggered roll out across six identified regions (see photo below). The four statewide PHPs selected are AmeriHealth Caritas of North Carolina, Inc., Blue Cross and Blue Shield of North Carolina – Healthy Blue, UnitedHealthcare of North Carolina, Inc. and WellCare of North Carolina. In addition, Carolina Complete Health was also awarded a regional contract for Regions 3 and 5. The first regions that will transition to this new managed care system will be Regions 2 and 4 on November 1, 2019. The remaining four regions (1, 3, 5 and 6) will transition on February 1, 2020.

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So how do these changes impact providers who care for Medicaid and Health Choice enrollees and for the enrollees themselves?

For Providers:

  1. As early as February 2019, the statewide PHPs will begin to formalize their provider networks. All providers that intend to participate in NC’s Medicaid managed care model will be negotiating service contracts with these plans.

  2. Providers can choose to contract with all four statewide PHPs or they may choose to contract with only select PHPs that cover the majority of the provider’s existing patients.

  3. For Regions 3 and 5, providers will have the option to contract with all four statewide plans plus the Regional PHP, if desired. Providers in counties that border Regions 3 and 5 should evaluate their patient panels for the number of patients residing in these Regions. Providers with sufficient patient volume from these regions may want to consider whether they should also contract with the Regional PHP.

  4. NCDHHS’s Medicaid managed care model also introduces the concept of Advanced Medical Homes (AMH), building upon the current Carolina ACCESS program. Within the AMH model, all primary care providers will be classified into tiers, based upon the level of care management and population health activities the provider is willing to assume. 

  5. Providers attest to the AMH Tiers via NC Tracks. If no action is taken, current Carolina ACCESS I providers default to AMH Tier 1; Carolina ACCESS II practices become AMH Tier 2.

  6. AMH Tier 3 is the most advanced level being introduced in 2019. Tier 3 gives the provider more autonomy in design of a care management program for their patients, but does require routine ability to ingest claims data, maintain a robust data analytic program, risk stratify patient populations, and provide a comprehensive care management program that meets NCDHHS’ intent for the AMH model. 

  7. Tier 3 practices will potentially be able to negotiate higher rates from the PHPs.

  8. AMH Tier 3 providers may offer all required AMH Tier 3 services directly, or may contract with an external partner, such as Emtiro Health, to provide all or some of the required services on their behalf.

For Medicaid enrollees in North Carolina:

  1. Medicaid enrollees eligible to enroll in a PHP will have to choose which plan they would like to enroll in during designated open enrollment periods. Open enrollment for enrollees who live in Regions 2 and 4 will begin in July 2019 and go through September 2019. Open enrollment for Regions 1, 3, 5, and 6 will be from October 2019 through December 2019.

  2. Enrollees who do not select a plan during the open enrollment period will be auto assigned to a plan by NCDHHS. This means that NCDHHS will pick the plan for the enrollee and sign them up.

  3. Prior to open enrollment periods, eligible Medicaid enrollees will be mailed information on how they can proceed to select and enroll with one of the PHPs. It is essential that Medicaid enrollees have updated contact information with their local Department of Social Services (DSS) to ensure that they receive these communications in a timely manner. 

  4. NCDHHS has contracted with an enrollment broker that will work with enrollees to explain differences in plans and have access to which networks providers have joined. The enrollment broker will provide impartial guidance to enrollees on their plan selection.


If you are either a provider or an enrollee and have any questions regarding the Medicaid Managed care contracts and process, please contact Emtiro Health directly at Info@EmtiroHealth.org.

Brea Neri