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Medicaid prepaid health plans join coordinate-care network
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Medicaid prepaid health plans join coordinate-care network

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The five prepaid health plans participating in North Carolina’s Medicaid transformation initiative have joined the statewide coordinated-care network NCCARE360.

The state’s game-changing Medicaid transition program debuted July 1 for an estimated 1.7 million North Carolinians.

Medicaid recipients were allowed to choose between four statewide PHPs for their physical and behavioral health coverage, or have a plan selected for them.

The PHPs are operated by Centene (doing business as WellCare of N.C.), AmeriHealth Caritas N.C., Blue Cross and Blue Shield of N.C. (doing business as Healthy Blue) and UnitedHealth Group. Carolina Complete Health Inc. serves a portion of the state.

NCCARE360 represents the nation’s first statewide coordinated-care network that connects individuals to local services and resources. It assists in coordinating whole-person care, while promoting health equity and addressing the social drivers that influence their members’ health.

“NCCARE360 is critical to the department’s goal of effectively delivering health, not just health care, by addressing the medical and non-medical drivers of health, including housing, food, transportation and interpersonal safety,” Dave Richard, deputy secretary of NC Medicaid, said in a statement.

NCCARE360 is part of the Healthy Opportunities initiative from the state Department of Health and Human Services.

The network allows PHPs to make electronic referrals, communicate in real time, securely share client information and track outcomes. Community members can search NCCARE360’s repository of more than 10,000 local services at nccare360.org/resources or email connect@nccare360.org.

At stake with Medicaid transformation: three-year PHP contracts for the four insurers that are projected to be worth $6 billion a year.

With two optional one-year extensions, a contract could be worth a total of $30 billion — among the largest vendor contracts awarded in state history.

Five years’ worth of often-controversial public health and legislative debate culminated in July 2020 when Democratic Gov. Roy Cooper signed Republican-sponsored legislation that provided pivotal start-up funds.

Richard said the transformation is designed to insure that Medicaid recipients will continue to see the same medical provider if available through the PHP, and that providers will get paid.

Managed care is a system under which people agree to see only certain doctors or go to certain hospitals, as in a health maintenance organization, or HMO, or a preferred provider organization, or PPO, health-insurance plan.

Under the former Medicaid system, providers are paid on a fee-for-service model administered by DHHS.

By contrast, the PHPs pay health-care providers a set amount per month for each patient’s costs. DHHS reimburse the PHPs.

There will be a limited number of special-needs individuals who will remain with fee-for-service providers.

All health plans are required to have the same Medicaid services, such as office visits, blood tests and X-rays. Health plans each have their own network of qualified doctors and health care professionals.

Essential health services continue to be covered under Medicaid Managed Care, including: primary care and hospital services; mental health and substance use services; pregnancy and childbirth; prescription drugs; and long-term services and supports.

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@rcraverWSJ

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