NC Medicaid is committed to effectively managing patients medical, social and behavioral conditions through a team-based, person-centered approach called Care Management.
- All Medicaid enrollees will have access to appropriate care management and coordination support across multiple settings of care, including a strong basis in primary care and connections to specialty care and community-based resources.
- Enrollees with high medical, behavioral or social needs should have access to a program of care management that includes the involvement of a multidisciplinary care team and the development of a written care plan.
- Local care management (care management performed at the site of care, in the home, or in the community where face-to-face interaction is possible) is the preferred approach, building on the strengths of the current care management structure.
- Care managers will have access to timely and complete enrollee-level information.
- As part of care management and care coordination, enrollees will have access to direct linkages to programs and services that address unmet health-related resource needs affecting social determinants of health, along with follow-up and ongoing planning.
- Care management activities will align with overall statewide priorities for achieving quality outcomes and value.
Advanced Medical Home Program
Medicaid enrollees will select a Prepaid Health Plan (PHP) which will delegate certain care management functions to state-designated Advanced Medical Homes (AMHs) at the local level. In order to provide these care management functions, AMHs may work with their affiliated health care system or make an arrangement, with an entity called a Clinically Integrated Network, (CIN) a Care Management vendor or other population health entity. For more information, please see the AMH web page.
Care Management for High-Risk Pregnancies (CMHRP)
All pregnant women enrolled in managed care through PHPs will continue to receive a coordinated set of high-quality clinical maternity services through the Pregnancy Medical Program (PMP). This program will be administered as a partnership between PHPs and local maternity care service providers (defined as any provider of perinatal services). A key feature of the program will be the continued use of the standardized screening tool to identify and refer women at risk for an adverse birth outcome to the Care Management for High-Risk Pregnant Women (CMHRP) program, a more intense set of care management services that will be coordinated and provided by Local Health Departments (LHDs). Together, these two programs will work to improve the overall health of women and newborns across the state. For more information, please see the CMHRP web page.
Care Management for At-Risk Children (CMARC)
The Medicaid program currently offers a set of care management services for at-risk children ages zero-to-five. The program coordinates services between health care providers, community program and supports, and family support programs. Responsibility for this population will be assumed by the PHPs with requirements that PHPs contract with LHDs for the provision of local care management services. For more information, please see the CMARC web page.
Long-Term Services and Supports (LTSS) Care Management
Medicaid beneficiaries of all ages may receive Long-Term Services and Supports (LTSS) program services for a short or extended time in an effort to support their goal of regaining or maintaining maximum health and independence when living with a chronic illness or disability. This collection of medical and non-medical programs are services provided in a variety of settings, including, but not limited to, nursing facilities, other group or private living settings and the community.
With the transition to managed care, Medicaid can offer significant opportunities to improve care coordination, access to community-based services and outcomes for beneficiaries receiving these services. A pivotal connecting component for the provision of LTSS program services and coordination of all care services is Care Management. For more information please see the LTSS Care Management webpage.
Pregnancy Management Program (PMP)
All pregnant women enrolled in managed care through the PHPs will continue to receive a coordinated set of high-quality clinical maternity services through the PMP. This program will be administered as a partnership between PHPs and local maternity care service providers (defined as any provider of perinatal services). A key feature of the program will be the continued use of the standardized screening tool to identify and refer women at risk for an adverse birth outcome to the CMHRP program, a more intense set of care management services that will be coordinated and provided by LHDs. Together, these two programs will work to improve the overall health of women and newborns across the state.
Transition of Care
Many Medicaid beneficiaries will enroll in Medicaid Managed Care and select a PHP, and will be able to change their PHP. Some beneficiaries will also disenroll from a PHP. In cases where beneficiaries transition between Medicaid Direct (fee-for-service) and Medicaid Managed Care delivery systems, the Department has put in place a number of processes and technology requirements to ensure continuity of care. For more information, please see the Transition of Care web page.
Transition of Current Programs for High-Risk Pregnancy and At-Risk Children into Managed Care Nov. 15, 2019
This webinar provides a high-level overview of the transition of current day Pregnancy Medical Home (PMH), Obstetric Care Management (OBCM) and Care Coordination for Children (CC4C) programs to managed care. It discusses the role of maternity and pediatric providers, LHDs and PHPs in continuing to care for high-risk pregnant women and at-risk children ages 0-5 under managed care. The webinar lays out how management for these populations fits into the broader managed care transition, the key elements of each program, and the infrastructure for program oversight and accountability.
For AMH training, pleasee see the AMH web page training page.
- Healthy Opportunities Pilot Program Guide for LHDs - Dec 8, 2022
- Care Management Forms
- Management of High-Risk Pregnancies and At-Risk Children in Managed Care - Frequently Asked Questions
- Management of High-Risk Pregnancies and At-Risk Children in Managed Care - Program Guide - May 12, 2021