This bulletin applies to NC Medicaid Managed Care Standard Plans.
The North Carolina Department of Health and Human Services (NCDHHS) is releasing updated information about the care management component of capitation payments to NC Medicaid Managed Care Standard Plans effective July 1, 2024.
The Standard Plan capitation rates include funding for care management. In the State Fiscal Year 2025 capitation rates, $10.66 PMPM is built in for care management staffing needs in accordance with the Department’s requirements and assumed average care management need levels within the Standard Plan populations. This figure is agnostic to the entity responsible for the delivery of care management and represents the expected cost to either a Standard Plan or an Advanced Medical Home (AMH) Tier 3 practice of delivering care management.
The $10.66 PMPM is an expected average cost for whole-person care management activities in accordance with the Department’s requirements and assumed average care management need levels within the Standard Plan populations. 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.
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 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. 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 NC Managed Care Capitation Rates – Care Management Assumptions (May 31, 2024). Additional information on NC Medicaid’s AMH program can be found on the Advanced Medical Home webpage.