NC Managed Care Capitation Rates – Updated Care Management Assumptions for Expansion Population

Includes rate considerations for Medicaid Expansion members effective Dec. 1, 2023.

The North Carolina Department of Health and Human Services (NCDHHS) is releasing updated information about the assumptions underlying the care management component of capitation payments to NC Medicaid Managed Care Standard Plans, including consideration for Medicaid expansion, effective Dec. 1, 2023.

As of Dec. 1, 2023, people ages 19 through 64 years with higher incomes are eligible for Medicaid coverage in North Carolina. For this expansion population, on average, $13.65 per member per month (PMPM) is the assumed cost of delivering care management in accordance with NCDHHS’s requirements, compared to $10.17 for non-expansion populations for State Fiscal Year 2024 (July 1, 2023-June 30, 2024).

The reason for this PMPM differential is that the expansion population is assumed to be a higher acuity population (as measured in total average service PMPMs) relative to the acuity of the average non-expansion population. A main driver of this acuity difference is that the non-expansion population is made up of a large proportion of lower acuity children utilizing North Carolina’s Temporary Assistance for Needy Families (TANF) program, compared to the expansion population which is limited to ages 19 through 64.

The Department is providing information on two separate rates (expansion and non-expansion) due to expected wide variation in the number of expansion members served by providers. However, Standard Plans may choose to implement care management payments as a single blended rate.

This information is based on a set of assumptions about care manager staffing ratios, by care management need level, and qualifications, which should be understood as averages rather than policies about how each care team must be constructed.

Care teams will vary in how they are staffed according to the needs of individual members and assigned panels. NCDHHS has not established minimum care management fees and maintains the expectation that Standard Plans and practices will arrive at mutually agreeable rates that are commensurate with the intensity and breadth of the care management being provided.

The Department expects Standard Plans to monitor advanced medical homes (AMHs) against program requirements and work with them to improve care management access and services for members. AMH Tier 3 practices are expected to comply with the requirements outlined in the Department’s Advanced Medical Home Manual.

By providing additional information on the assumptions NCDHHS used to develop components of the care management component of capitation payments, Standard Plans and AMH Tier 3 practices will be better positioned to enter into care management contracts that enable all parties to meet NCDHHS’s expectations in the execution of care management responsibilities and achievement of improved health outcomes. The Department is exploring ways to further improve monitoring and stewardship of care management program funds in coordination with Standard Plans.

Details on the current care management rate assumptions can be found in the Care Management Assumptions document updated Jan. 3, 2024. Additional information on NC Medicaid’s AMH program can be found on the Advanced Medical Home webpage.

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