Quality Management and Improvement

The Department’s goal is to improve the health of North Carolinians through an innovative, whole-person centered, and well-coordinated system of care and measurement of quality, which addresses both medical and non-medical drivers of health.

As North Carolina transitions to NC Medicaid Managed Care, the Department will work with Prepaid Health Plans (PHPs) to develop a data-driven, outcomes-based continuous quality improvement process, This will:

  • Focus on rigorous outcome measurement compared to relevant targets and benchmarks,
  • Promote equity through reduction or elimination of health disparities, and
  • Appropriately reward PHPs and, in turn, providers for advancing quality goals and health outcomes.

Quality Strategy

The Department’s Quality Strategy details NC Medicaid Managed Care aims, goals and objectives for quality management and improvement and details specific quality improvement (QI) initiatives that are priorities for the Department. 

The updated NC Medicaid Managed Care Quality Strategy is currently open for Public Comment until Jan. 6, 2025. Feedback can be provided to Medicaid.Quality@dhhs.nc.gov.

NC Medicaid Annual Health Disparities Report

NC Medicaid serves roughly 3 million low-income individuals and families, placing it in a unique position to track health disparities and improve the health of populations that have been historically marginalized.

To help identify and address these disparities, the North Carolina Department of Health and Human Services (NCDHHS) Division of Health Benefits (DHB) developed the 2022 Annual Health Disparities Report, which outlines health disparities across the entire NC Medicaid beneficiary population. The report looks at 50 health care quality measures and identifies health disparities across eight demographic stratifications. The results are organized into six domains: beneficiary experience, child and adolescent health, women’s health, mental health, substance use and health care utilization.

The links to the full report and a six-page brief are available below:

Quality Measure Performance and Targets for the Advanced Medical Home (AMH) Measure Set

To ensure delivery of high-quality care under the managed care delivery system, NC DHHS has developed the NC Medicaid Managed Care Quality Strategy and identified a set of quality metrics that it will use to assess health plans’ performance across their populations.

The Department has identified a subset of these measures for health plans to use to monitor Advanced Medical Home (AMH) performance and calculate AMH performance incentive payments. The first quality performance period for AMHs began in January 2022.

These baseline data and targets are shared as a reference for AMHs. An AMH practice (National Provider Identifier (NPI) + location code) will have its own rate that may be above or below the baseline rates provided. AMHs should negotiate target performance rates with health plans.

Additional information and resources for AMHs are available on the NC Medicaid Advanced Medical Home webpage.   

Prenatal and Postpartum Care F Codes

NC Medicaid’s Obstetrical Services Clinical Coverage Policy No: 1E-5, updated June 15, 2024, requires the use of two new CPT billing codes for prenatal and postpartum care. These codes will assist in capturing information about the timeliness of prenatal and postpartum care provided to NC Medicaid members. The PPC F Codes Fact Sheet and FAQ document aim to give providers and practices more information about these new F codes, why they are important, and how they should be used. 

Access Monitoring Review Plan (AMRP)

The Access Monitoring Review Plan (AMRP) provides an overview of access to care for North Carolina Medicaid Direct beneficiaries from 2019 through 2022. Medicaid Direct is the traditional fee-for-service Medicaid program in North Carolina. For more information, visit the NCDHHS Medicaid Direct webpage.

The AMRP analyzes the extent to which the health care access needs of Medicaid Direct beneficiaries are being met by examining provider availability and accessibility, beneficiaries’ utilization of services, health care performance measures and measures of patient experience. Access to care is important for all NC Medicaid enrollees and this report is just one tool NC Medicaid uses to track and analyze that access.

Standard Plan Withhold Program

The North Carolina Department of Health and Human Services remains dedicated to improving the health of North Carolinians through an innovative, equitable, whole-person-centered and well-coordinated system of care that supports both medical and nonmedical drivers of health.

A key component of North Carolina’s Quality Strategy includes measuring and incentivizing performance improvement as part of Medicaid transformation. Withhold programs are one mechanism to encourage performance improvement in a variety of domains and have been implemented in other state Medicaid managed care programs.

In a withhold arrangement, a portion of health plans’ expected capitation payment is withheld, and plans must meet targets (e.g., quality measure performance targets) to receive withheld funds from the Department once performance is known at the conclusion of a defined performance period, typically the annual quality measurement cycle.

2024 will be the first year of NC Medicaid's Standard Plan quality withholds program. Additional details are provided in the 2024 North Carolina Medicaid Standard Plan Withhold Program Guidance (v. 9/1/23). Information about the program’s second year (2025) can be found in the 2025 North Carolina Medicaid Standard Plan Withhold Program Guidance.

NC Medicaid uses a framework to inform annual consideration of the Standard Plan Withhold Program performance measure set.
Standard Plan Withhold Program Measure Set Decision-Making Rubric - April 2024

Tele-Transformation in North Carolina 

The North Carolina Department of Health and Human Services is pleased to share a policy evaluation brief, Tele-Transformation in North Carolina: Telehealth Policy Lessons Learned During the COVID-19 Pandemic and Beyond and companion chart pack, below:

The brief highlights North Carolina’s approach to telehealth policymaking, both in response to the COVID-19 pandemic and thereafter, to serve as a model to other states undertaking telehealth policymaking and evaluation. This brief includes:

  1. An overview of North Carolina’s evolution in telehealth policy.
  2. The state’s decision-making criteria used to determine temporary and permanent telehealth policy changes.
  3. Key findings from the state’s evaluation of telehealth utilization between March 2020 and December 2022 (with additional detail included in the chart pack).
  4. Considerations for other states.

Monitoring and Evaluation of the Medicaid Reform Demonstration

The Sheps Center for Health Services Research is the independent evaluator for the state’s 1115 demonstration, the North Carolina Medicaid Reform Demonstration. The evaluation assesses the impact of the transition to NC Medicaid Managed Care, the substance use disorder (SUD) component of the demonstration and the Healthy Opportunities Pilots.

For the full reports, visit the Evaluation of the Medicaid Reform Demonstration page.  

Additionally, NC Medicaid completes quarterly monitoring reports for the Managed Care/Healthy Opportunities Pilot and Substance Use Disorder (SUD) portions of the demonstration. To view the monitoring reports, visit the 1115 Waiver Demonstration Quarterly Monitoring Reports page.

Quality Survey Results 

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a patient experience survey that serves as a national standard for measuring and reporting respondents’ experiences with their health care. The Medicaid Provider Experience Survey evaluates the impact of the North Carolina Medicaid Transformation on primary care and obstetrics/gynecology (Ob/Gyn) practices that contract with NC Medicaid.

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surveys

Consumer Assessment of Healthcare Providers and Systems Survey Results Released - Medicaid Bulletin, published Aug. 18, 2022

2024 CAHPS Survey - Three Years into Managed Care

2023 CAHPS Survey - Two Years into Managed Care

2022 CAHPS Survey - One Year into Managed Care

2021 CAHPS Survey

Medicaid Provider Experience Surveys

Baseline Medicaid Provider Experience Survey Report Released - Medicaid Bulletin, published Aug. 18, 2022 

2024 Medicaid Provider Experience Survey – Three Years into Managed Care

2023 Medicaid Provider Experience Survey - Two Years into Managed Care

2022 Medicaid Provider Experience Survey – One Year into Managed Care

Baseline Medicaid Provider Experience Survey

Home and Community Based Services (HCBS) CAHPS Survey

2024 HCBS CAHPS Toolkit

The Home and Community Based Services (HCBS) Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey gathers direct feedback from Medicaid beneficiaries receiving HCBS about their experiences and the quality of the services and supports they receive. To increase response rates and survey engagement for the 2024 survey administration, NC Medicaid is asking for the support of providers, health plans, care managers and community partners to share information about this survey with their relevant adult (18 years of age or older) Medicaid beneficiaries.

2023 HCBS CAHPS 

In 2023, NC Medicaid conducted the Home and Community Based Services (HCBS) Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. The focus of this survey was to understand Medicaid beneficiaries’ experiences and the quality of services and supports they receive. The following documents are the full report and the two-page summary report highlighting key findings:

NC Medicaid Managed Care Qualitative Evaluation

Qualitative interviews with Prepaid Health Plans (PHPs) and provider organizations are part of a larger multi-year evaluation of the transition from NC Medicaid Direct (fee-for-service) to NC Medicaid Managed Care under the 1115 demonstration waiver. Summaries of qualitative evaluation findings to date are provided below:

Demonstration Year 3 Summary – Providers

Demonstration Year 3 Summary – PHPs

Demonstration Year 4 Summary – Providers

Quality and Accountability

While the mechanics of reimbursement for health care are changing, the goal of NC Medicaid remains improving beneficiaries’ health and well-being by delivering the right care, in the right place, at the right time. In designing this transition, the Department is committed to leveraging engagement through the managed care program with PHPs and their contracted providers to improve the quality of health care beneficiaries receive.

North Carolina identified targeted quality indicators that will serve as guides for the Department, contracted plans and providers. These performance indicators will be crucial to assess the success of the new approach.

Provider Health Plan Quality Performance and Accountability Concept Paper

Annual Quality Report

The NC Medicaid Annual Quality report assesses NC Medicaid’s performance on various quality measures in an effort to evaluate access to care, utilization of services, and health outcomes among beneficiaries. Performance is assessed both across years and compared to national medians. The report identifies strengths, areas of concern, and growth opportunities linked to the goals identified in the NC Medicaid Managed Care Quality Strategy. NC Medicaid will work with health plans, Local Management Entity/Managed Care Organizations (LME/MCOs), Primary Care Case Management (PCCM) entities, and providers to monitor and make improvements in quality performance year over year. 

External Quality Review 

The EQR Technical Report is a program-wide detailed technical report summarizing the findings of the annual external quality review and quality of care across all PHPs. It includes an executive summary of the objectives of the EQR as well as a description of the EQR process, including data collection tools, documents requested, offsite and onsite activities, a description of the data reviewed and a summary of findings and conclusions drawn from the data.

Encounter Data Validation

The 2023-2024 Encounter Data Validation report summarizes the findings from an analysis performed by the EQRO. The EQRO conducted a comparative analysis of DHB’s electronic encounter data for completeness and accuracy. The goal of this activity was to evaluate the extent to which the encounter data in DHB’s Encounters Processing Solution (EPS) database are complete and accurate for encounters with dates of service between July 1, 2022 and June 30, 2023.

2023-2024 Encounter Data Validation report 

Smarter Spending: Value-Based Purchasing under Managed Care

NC Medicaid will increasingly tie payment to value and will support PHP and provider contracting flexibility that helps providers deliver care in new ways. PHPs will play a critical role in driving forward Medicaid’s Value-Based Purchasing (VBP) goals. 

Learn more about Value-Based Purchasing.

NC Medicaid Quality Fact Sheet Series

The NC Medicaid Quality Fact Sheet series aims to detail NC Medicaid’s performance in key areas. As NC Medicaid leads many activities to survey, evaluate, and improve upon its performance, the documents below distill quality measure information for public use, providing readers insight into NC Medicaid’s performance across select domains and initiatives aimed at improving performance.

Quality Measurement Technical Specifications

This document provides an overview of the Department’s plans for promoting high-quality care through NC Medicaid Managed Care based on the aims, goals and objectives outlined in the Department's Quality Strategy. It includes a list of the quality measures intended for monitoring beneficiary access to care, utilization of services, and health outcomes, and health plan performance and improvement processes. The Department will update this document as needed and on an annual basis. 

NC Medicaid Quality Measurement Technical Specifications Manual - April 14, 2025

Archived Quality Measurement Technical Specifications

Accreditations

Tab/Accordion Items

Standard Plans Accreditation Status, Updated as of Dec. 5, 2024

The Standard Plans are seeking Health Plan Accreditation and Health Equity Accreditation by June 2025.

Plan Name

Accreditation Status

Accrediting Entity

Accreditation Program

Accreditation Level

AmeriHealth CaritasScheduledNCQAHealth Equity AccreditationN/A
AmeriHealth CaritasIn ProcessNCQAHealth Plan AccreditationN/A
Carolina Complete HealthScheduledNCQAHealth Plan AccreditationN/A
Carolina Complete HealthScheduledNCQAHealth Equity AccreditationN/A
Healthy BlueScheduledNCQAHealth Plan AccreditationN/A
Healthy BlueAccreditedNCQAHealth Equity Accreditation PlusN/A
United HealthcareAccreditedNCQAHealth Plan AccreditationN/A
United HealthcareAccreditedNCQAHealth Equity AccreditationN/A
WellCareScheduledNCQAHealth Plan AccreditationN/A
WellCareAccreditedNCQAHealth Equity AccreditationN/A

Tailored Plans Accreditation Status, Updated as of Dec. 5, 2024

The Tailored Plans are seeking Health Plan Accreditation with LTSS Distinction by June 2027.

Plan NameAccreditation StatusAccrediting EntityAccreditation ProgramAccreditation Level
Alliance HealthScheduledNCQAHealth Plan Accreditation N/A
Partners Health ManagementScheduledNCQAHealth Plan Accreditation N/A
Trillium Health ResourcesInterim AccreditationNCQAHealth Plan Accreditation N/A
Vaya HealthInterim AccreditationNCQAHealth Plan Accreditation N/a

 

2022 Quality Forums

Tab/Accordion Items

  • Can telehealth improve access to care?
  • What is the efficacy of telehealth for mental health and addiction treatment?
  • How can data inform evolving policies regarding telehealth?

Presentation

Recording

  • What are the ASAM Placement Criteria and how could they improve quality and outcomes from addiction treatment? 
  • What are the challenges and potential unintended consequences of implementing the ASAM criteria and how can they be avoided?
  • How can ASAM implementation be monitored and ASAM assessments used to inform needs and network adequacy assessments?

Presentation

Recording

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