NC Medicaid Managed Care Capitation Rates – Care Management Assumptions

Updated information about the assumptions underlying the care management component of capitation payments to Standard Plans

The North Carolina Department of Health and Human Services is releasing updated information about the assumptions underlying the care management component of capitation payments to NC Medicaid Managed Care Prepaid Health Plan (PHPs) Standard Plans. The PHP Standard Plan capitation rates developed by the Department reflect its belief that investment in robust community-based care management will drive improvements in care outcomes and achieve greater value from the State’s Medicaid dollar.

The new document provides assumptions for the Standard Plan managed care capitation rates for State Fiscal Year 2023 (July 1, 2022-June 30, 2023). Rate updates will be considered as part of capitation rate setting for future state fiscal years.

Under the Advanced Medical Home (AMH) Tier 3 program, Standard Plans must delegate certain care management functions and responsibilities to certified practices that meet the program’s requirements. Where such delegation occurs, PHPs are expected to pay care management fees sufficient to support the delegated activities. While the Department has declined to establish minimum care management fees to date, the expectation underlying the AMH Tier 3 model is that PHPs and practices will arrive at mutually agreeable rates that are commensurate with the intensity and breadth of the care management being provided. The Department wants to ensure that the care management fees being contemplated by PHPs are adequate to support the level of quality of community-based care management services that DHHS expects of its AMH Tier 3 practices.

By providing additional information on the assumptions the Department used to develop components of the care management component of capitation payments, PHPs and AMH Tier 3 practices will be better positioned to enter into care management contracts that enable all parties to meet the Department’s expectations in the execution of care management responsibilities and achievement of improved health outcomes.

Details on the current care management rate assumptions are available in Programmatic Guidance on Care Management Component of PHP Capitation Rates. Additional information is available on the NC Medicaid Advanced Medical Home webpage.

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