State health officials are taking another step toward reform of the N.C. Medicaid program, this time addressing requirements for physical managed care organizations.

In September 2015, the Republican-controlled legislature approved shifting Medicaid from a fee-for-service structure to a managed care structure.

The current Medicaid waiver request to federal health regulators proposes a hybrid public- and private-sector reform solution that eventually would combine physical and behavioral health into a whole-body care platform.

The N.C. Department of Health and Human Services projects about $400 million in savings in the first five years of implementation.

The Democratic administration of Gov. Roy Cooper revealed in August its proposal for overseeing the approved state Medicaid reform plan. The 77-page plan deals with the Medicaid and the N.C. Health Choice programs.

On Friday, DHHS released two requests for information.

One addresses physical MCOs, including a statement of interest from prospective prepaid health plans. The deadline for responses is 2 p.m. Nov. 22.

The other focuses on the financial aspects of managed care, including information on the proposed capitation rate setting methodology. The deadline for responses is 2 p.m. Dec. 1.

Prepaid plans would receive a monthly fixed, or “capitated,” payment from the state Medicaid program that the DHHS said “will be actuarially sound, transparent and fair.”

DHHS expects to release in the spring its request for proposal information for potential prepaid health plans.

Dr. Mandy Cohen, the state’s health secretary, told a joint legislative oversight health care committee in October that DHHS’ goal is gaining Centers for Medicare and Medicaid Services approval in the spring.

If that occurs, state health regulators would be able to issue requests for proposals for statewide oversight groups and regional provider-led entities.

The current timeline is for three to five statewide groups and up to 10 provider-led entities to be chosen in the fall of 2018.

Eleven of the state’s largest not-for-profit health care systems are pooling resources into North Carolina Provider Owned Plans that would operate as a potential statewide group.

“Our top priority is the health and well-being of the beneficiaries we serve,” Cohen said. “We want to do everything we can to build an innovative and whole-person centered system of care that focuses on both medical and non-drivers of health.”

For additional information, go to ncdhhs.gov/nc-medicaid-transformation.

Cohen said the state remains on pace to submit a Medicaid waiver amendment this fall that includes changes based primarily on recent statewide feedback.

Then-Gov. Pat McCrory’s administration submitted a Medicaid waiver request to the federal Centers for Medicare and Medicaid Services on June 1, 2016. The request did not include expanding the state program for potentially more than 500,000 North Carolinians.

The Cooper administration has attempted, with no success to date, to work through the federal courts to gain permission from the Trump administration to expand the program.

Cohen said that achieving a July 1, 2019, launch date “is achievable but ambitious.”

Dave Richard, deputy secretary for the state’s Medicaid program, said the Cooper administration plan has three main focuses:

  • Integrating whole-body services to combined physical, mental, intellectual and developmental disabilities and substance-use disorders;
  • Tackling unmet social needs and their effect on overall health, such as improving telemedicine access and putting more focus on the state’s opioid addiction crisis; and
  • Enhancing successful existing programs such as care management while supporting providers and beneficiaries through any changes, such as creating a “one-stop shop” for streamlining beneficiary eligibility and enrollment processes.
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