North Carolina Medicaid is dedicated to enhancing patient well-being through comprehensive and coordinated care management programs. These initiatives are built upon a team-based, person-centered approach, ensuring that individuals receive the right support across various healthcare settings. The core aim of these Medicaid Care Management Programs is to effectively address the medical, social, and behavioral health needs of enrollees.
Every Medicaid enrollee in North Carolina benefits from access to appropriate care management and coordination. This support network spans multiple care environments, emphasizing a strong foundation in primary care alongside seamless connections to specialist services and vital community-based resources. For enrollees facing complex medical, behavioral health, or social challenges, Medicaid care management programs offer a more intensive level of support. This includes the involvement of a multidisciplinary care team and the development of a personalized, written care plan.
The preferred approach for delivering these crucial services is local care management. This model prioritizes care delivery within the enrollee’s community, at their healthcare site, or even in their home, facilitating face-to-face interactions and building upon the existing strengths of the current care management framework. To ensure effective care coordination, care managers are provided with timely and complete information at the enrollee level. This access to comprehensive data empowers them to make informed decisions and provide tailored support.
Furthermore, Medicaid care management programs in NC are committed to addressing the social determinants of health. As an integral part of care management and coordination, enrollees are directly connected to programs and services designed to address unmet health-related resource needs. This proactive approach includes consistent follow-up and ongoing planning to ensure that enrollees receive holistic support. All care management activities within these programs are carefully aligned with overarching statewide priorities focused on achieving high-quality outcomes and maximizing value within the healthcare system.
Key Medicaid Care Management Programs in NC
North Carolina’s commitment to care management is further demonstrated through several targeted programs designed to meet specific population needs:
Advanced Medical Home (AMH) Program
The Advanced Medical Home (AMH) program is a cornerstone of NC Medicaid’s managed care strategy. Medicaid enrollees in North Carolina select a Prepaid Health Plan (PHP), and these PHPs delegate specific care management responsibilities to state-designated Advanced Medical Homes at the local level. AMHs are crucial in delivering on-the-ground care management services. To effectively carry out these functions, AMHs may collaborate closely with their affiliated healthcare systems. They also have the option to partner with entities such as Clinically Integrated Networks (CINs), specialized Care Management vendors, or other population health organizations. These partnerships ensure a robust and comprehensive approach to care management within the AMH framework. For more detailed information, please visit the Advanced Medical Home webpage.
Care Management for High-Risk Pregnancies (CMHRP)
Pregnant women enrolled in Medicaid managed care in North Carolina receive coordinated, high-quality clinical maternity services through the Pregnancy Medical Program (PMP). This program operates through a collaborative partnership between PHPs and local maternity care service providers, encompassing all providers of perinatal services. A vital component of the PMP is the consistent use of a standardized screening tool. This tool is essential for identifying and referring women who are at high risk of adverse birth outcomes to the Care Management for High-Risk Pregnant Women (CMHRP) program. CMHRP provides a more intensive suite of care management services, expertly coordinated and delivered by Local Health Departments (LHDs). Through the combined efforts of the PMP and CMHRP, North Carolina strives to improve the overall health outcomes for women and newborns throughout the state. To learn more, please refer to the CMHRP webpage.
Care Management for At-Risk Children (CMARC)
NC Medicaid provides specific care management services for at-risk children aged zero to five through the Care Management for At-Risk Children (CMARC) program. This program is designed to ensure seamless coordination of services among healthcare providers, community programs, various support systems, and family support programs. Under managed care, PHPs assume responsibility for this population, with the requirement that they contract with LHDs to deliver local care management services. This collaboration ensures that at-risk young children receive comprehensive and community-based support. Additional details are available on the CMARC webpage.
Long-Term Services and Supports (LTSS) Care Management
Medicaid beneficiaries of all ages who are living with chronic illness or disability may be eligible for Long-Term Services and Supports (LTSS) program services. These services are available for both short-term and extended periods, aiming to support individuals in achieving or maintaining their maximum possible health and independence. LTSS encompasses a range of medical and non-medical programs and services delivered in diverse settings. These settings include nursing facilities, group or private living arrangements, and within the community itself. The transition to managed care offers significant opportunities for Medicaid to enhance care coordination, improve access to community-based services, and achieve better outcomes for beneficiaries receiving LTSS. Care management serves as a crucial link in the effective provision of LTSS program services and the overall coordination of all care services for these individuals. For further information, please consult the LTSS Care Management webpage.
Pregnancy Management Program (PMP)
As previously mentioned, the Pregnancy Management Program (PMP) ensures that all pregnant women enrolled in Medicaid managed care through PHPs continue to receive a coordinated and high standard of clinical maternity services. This program is a collaborative effort between PHPs and local maternity care providers. A key aspect of the PMP is the ongoing use of a standardized screening tool to identify and appropriately refer women at risk for adverse birth outcomes to the CMHRP program. The CMHRP program then provides a more intensive level of care management, coordinated and delivered by LHDs. Working in tandem, the PMP and CMHRP programs are dedicated to enhancing the health and well-being of women and newborns across North Carolina.
Transition of Care
Recognizing that Medicaid beneficiaries may transition between different care systems, NC Medicaid has established processes to ensure continuity of care. Many beneficiaries will enroll in Medicaid Managed Care and select a PHP, and they retain the ability to change their PHP if needed. Additionally, some beneficiaries may disenroll from a PHP altogether. To address these transitions, particularly when beneficiaries move between Medicaid Direct (fee-for-service) and Medicaid Managed Care delivery systems, the Department has implemented specific processes and technology requirements. These measures are designed to maintain seamless continuity of care, minimizing disruptions for beneficiaries during these transitions. More information can be found on the Transition of Care webpage.
Training and Resources
Transition of Current Programs for High-Risk Pregnancy and At-Risk Children into Managed Care Nov. 15, 2019
A webinar was conducted on November 15, 2019, to provide a comprehensive overview of the transition of existing Pregnancy Medical Home (PMH), Obstetric Care Management (OBCM), and Care Coordination for Children (CC4C) programs into managed care. This training session outlined the roles of maternity and pediatric providers, LHDs, and PHPs in continuing to deliver care to high-risk pregnant women and at-risk children aged 0-5 under the new managed care framework. The webinar detailed how care management for these specific populations integrates into the broader managed care transition, highlighted the key components of each program, and explained the infrastructure established for program oversight and accountability.
For specific training related to the Advanced Medical Home program, please visit the AMH training page.
