Overview and History of Managed Care in North Carolina

GOALS: Create community health networks to achieve long-term quality, cost, access and utilization objectives.  

APPROACH: Create medical homes by enrolling all eligible Medicaid recipients into Community Care of North Carolina/Carolina ACCESS (CCNC/CA). Provide health education to all plan members and assist them in maximizing their own health care through self management.

• Risk Contracting
• Community Care of North Carolina/Carolina ACCESS (CCNC/CA)
  • Carolina ACCESS
  • ACCESS II/III
• Member Enrollment
• Member Education
• Participation Requirements of Primary Care Providers
• Referral/Authorization
• Services Exempt from Authorization by the PCP
• Key Program Resources

Risk Contracting

In 1986, North Carolina began offering managed care to Medicaid recipients eligible for enrollment by contracting with Kaiser Permanente, an HMO. This option was available only in Mecklenburg, Durham and Wake counties. In 1996, the state contracted with five HMOs to serve in Mecklenburg County. The program was called Health Care Connection. Health Care Connection was extended into four other counties; however, because of an insufficient population base in these counties, the HMOs withdrew participation in all but Mecklenburg County. On December 1, 2002, South Care became the only HMO serving Mecklenburg County. That contract ended effective August 1, 2006. North Carolina no longer contracts with an HMO to serve the Medicaid population.

Community Care of North Carolina/Carolina ACCESS (CCNC/CA)

Today, CCNC/CA combines Carolina ACCESS and ACCESS II/III. Although these two primary care case management health plans exercise differences in the level of services that are available, they are similar in how recipients are enrolled and how providers are enrolled into the program.

Carolina ACCESS

The Center for Medicaid/Medicare Services (CMS) approved a 1915(b) waiver in April 1991, for North Carolina to implement a primary care case management program, Carolina ACCESS. The North Carolina Department of Health and Human Services (DHHS) initiated Carolina ACCESS as a pilot in five counties. The program was co-sponsored by the Division of Medical Assistance and the Office of Rural Health and Community Care.  The purpose was to create a system of coordinated health care for Medicaid recipients. The program was designed to provide a medical home with a primary care provider (PCP) to coordinate patient care by providing and/or authorizing services. Carolina ACCESS pays providers fee for service and pays the recipient’s PCP a management fee for coordinating patient care. The management fee is based on per member/per month (PM/PM). Carolina ACCESS was successful in opening access to primary care and increasing preventive services. It became statewide in 1998. Because of the rural nature of this state, Carolina ACCESS continues to serve Medicaid recipients. Carolina ACCESS created the infrastructure for ACCESS II/III, an enhanced community based primary care case management health plan.

ACCESS II/III

In 1998, the Division of Medical Assistance and the Office of Rural Health and Community Care once again collaborated to enhance the basic Carolina ACCESS program and launched a new approach to providing health care for Medicaid recipients. CCNC operates statewide.  CCNC works directly with community providers who have contracted with the state to be a Carolina ACCESS PCP. The program builds private and public partnerships where community providers and resources plan cooperatively for meeting patient needs. The responsibility for managing the care of the enrolled population falls to the community network. Performance and improvement are the responsibility of those who actually deliver the care. Medical providers are paid fee for service and PCPs participating in a network are paid a management for based on PM/PM. The network in which the provider is enrolled also receives a management fee based on the number of Medicaid recipients enrolled with the network. All funds are kept local and recycle back into the community for patient care. Because health care is planned and provided on the community level, larger community health issues can be addressed. A majority of Medicaid recipients enrolled in managed care are linked with a CCNC network. There are fourteen (14) networks operating statewide. These networks are private non-profit and contract with the state which provides operating expenses for staff and health care initiatives. Below is a list of the networks and the counties that form each network.

• Access Care – 150 provider sites including UNC health care system
• Access II Care of Western NC – Buncombe, Henderson, Madison, Mitchell, McDowell, Polk, Transylvania and Yancey
• Access III of Lower Cape Fear – Bladen, Brunswick, Columbus. New Hanover, Onslow and Pender
• Carolina Collaborative Community Care – Cumberland
• Carolina Community Health Partnership – Cleveland and Rutherford
• Central Piedmont Access II – Davie, Forsyth, Stokes, Surry, Wilkes, and Yadkin
• Community Care Partners of Greater Mecklenburg – Anson, Mecklenburg, and Union
• Community Care Plan of Eastern Carolina – Beaufort, Bertie, Camden, Carteret, Chowan, Craven, Currituck, Dare, Duplin, Edgecombe, Gates, Greene, Halifax, Hertford, Hyde, Jones, Lenoir, Martin, Nash, North Hampton, Pamlico, Pasquotank, Perquimans, Pitt, Tyrell, Washington and Wilson
• Community Health Partners – Gaston and Lincoln
• Northern Piedmont Community Care – Durham, Granville, Person, Vance and Warren
• Partnership for Health Management l- Guilford, Randolph and Rockingham
• Sandhills Community Care Network – Harnett, Hope, Lee, Montgomery, Moore, Richmond and Scotland
• Southern Piedmont Community Care Plan – Cabarrus, Rowan, and Stanly.

CCNC networks are putting into place the management tools that programs need to achieve improved performance which in turn provides Medicaid cost savings. These tools are:

• Implementing best practices
• Implementing disease management
• Managing high-risk patients
• Managing high-cost services
• Building accountability

Physician leaders from all fourteen networks design and develop initiatives to improve health outcomes. The following are initiatives that are currently underway

• Asthma disease management
• Congestive health failure disease management
• Diabetes disease management Emergency Room Initiatives
• Case management of high risk/high cost patients

Other initiatives currently being developed are:

• Aged, blind, disabled chronic care
• Health choice (North Carolina’s children’s health insurance program, CHIP)
• COPD

Today, there is no distinction between ACCESS II and ACCESS III. All networks have developed into full community operated programs.  More Information on the CCNC Website

Member Enrollment

Medicaid recipients are enrolled in CCN/CA by the Department of Social Services located in the county in which they reside. Enrollment can be done at anytime during the recipient’s eligibility period; however, it is required at application or review for continuation of eligibility. The program aid category of eligibility determines if a recipient is mandatory, optional, or ineligible for enrollment in CCNC.

Exceptions to the Mandatory Program Aid Categories:

1. Any Medicaid recipient who receives Medicare in addition to Medicaid becomes optional for enrollment;
2. Any child under the age of 21 years and who is also identified as having special needs becomes optional for enrollment. Special needs is defined as:
• A child receiving SSI;
• A child in foster care or receiving adoption assistance;
• Self-identified as having special needs
3. Current or potential enrollees who are mandatory can request an exemption from participation for medical reasons. Recipients can request exemption request forms from the county dss. Each request is evaluated on an individual basis. Medical records may be requested to determine if an exemption will be approved.

Member Education

When a person applies for Medicaid or when a Medicaid recipient is being reviewed for continuing eligibility, a county dss representative is responsible for providing information to the client about the Carolina ACCESS health plan and how they access care as members. Education includes:

• Definition of the medical home concept and the benefits this offers for quality health care;
• Medicaid covered services are not changed; however, CA provides accessibility to physician services, coordination of health care services,  enhanced services through case management/disease management;
• Availability of medical advice/services 24/7 from the PCP;
• Ability to choose a medical home and the frequency with which a medical home can be changed;
• Necessity for contacting the medical home for an appointment to become an established patient;
• No longer a need to use the Emergency Department for primary care;
• Right to file a complaint against a PCP for situations of poor quality of care which may be caused by contractual violations, physical/sexual/ substance abuse, professional conduct, or program fraud/abuse if this is suspected.
• Referrals for specialty services.
• Importance of getting preventative services, i.e., well check ups, pap smears, mammography, diabetic screenings, etc.
• Process for requesting an exemption from enrollment for medical reasons.
• Information on services not requiring authorization by the PCP.

Participation Requirements of Primary Care Providers (PCPs)

The PCP is key to the ability to achieve the goals of CCNC/CA. A medical provider who is interested in serving as a Carolina ACCESS PCP must complete an application for participation. The application will be reviewed by the Provider and Recipient Services Section at DMA who notifies the applicant if the application is approved or denied and the reason for the denial. If for any reason a candidate does not or cannot meet these criteria, an exceptions’ review will be done. An exception may be granted if it is determined that access to care for Medicaid recipients would be impeded if all criteria are not met. Each request for an exception is evaluated on an individual basis. A candidate for participation must meet the criteria below:

• Perform primary care that include certain preventative services;
• The ability to create and maintain a patient/doctor relationship for the purpose of providing continuity of care;
• Establish hours of operation for treating patients at least 30 hours per week;
• Provide access to medical advice/services 24/7;
• Maintain hospital admitting privileges or have a formal agreement with another doctor based on ages of the members accepted;
• Refer or authorize services to other providers when the service cannot be provided by the PCP;
• Use reports provided by the DMA managed care section as guides in maintaining the level of care that meets the goals of CCNC and patient needs. Reports are available via the web and paper copies that are mailed.

In order to serve as a PCP in a CCNC/CA network, the provider must first be enrolled with DMA as a Carolina ACCESS PCP. An interested provider may contact the regional managed care consultant for more information. The provider will be required to sign a contract with the local network.

Referral/Authorization

 In order to manage a patient’s health care and assure access to all necessary health care services, the PCP is contractually obligated to refer patients or authorize treatment for patients when unable to provide the necessary service. It is the domain of the PCP to refer/authorize treatment and define the scope. The PCP can authorize refer/authorize services by telephone or in writing. In referring or authorizing a service:

•  The PCP's authorization number must be communicated to the service provider;
•  The PCP defines the scope of a referral which includes the number of visits being authorized and the extent of the diagnostic evaluation;
• The PCP should be informed if a secondary referral, sending patient to a second provider for the same diagnosis, should be made. The authorization number should accompany the secondary referral;
• A provider who has received a referral should consult the  PCP before referring to a secondary provider for situations not related to the diagnosis of the first referral;
• The PCP may authorize care retroactively; however, it is at the discretion of the PCP.

If a non-PCP provider has provided a service and is denied authorization by the PCP, the service provider may request an override. (Carolina ACCESS Override Request) To request an override the provider must contact the Medicaid fiscal agent. Contact information is provided on the form.

Services Exempt from Authorization by the PCP

Enrollees can receive the following services from any qualified provider who accepts Medicaid (subject to Medicaid coverage policies and limitations) without first obtaining authorization from their primary care physician:

• Ambulance
• Anesthesiology
• At Risk Case Management
• CAP Services
• Certified Nurse Anesthetist
• Child Care Coordination
• Dental
• Developmental Evaluation Centers
• **Emergency Services provided in a hospital emergency department or a hospital owned urgent care center.
• Eye Care Services (limited to CPT codes: 92002, 92004, 92012, 92014, and Diagnosis codes related to conjunctivitis: 370.3; 370.4; 372.0; 372.1; 372.2; 372.3)
• Family Planning (Including Norplant)
• Health Department Services
• Hearing Aids (Under age 21)
• Hospice
• Independent & Hospital Lab Services
• Maternity Care Coordination
• Optical Supplies/Visual Aids
• Pathology Services
• Pharmacy
• Psychiatric/Mental Health (Psychiatrists, Psychiatric Hospitals, Area Mental Health Programs, Psychiatric Facilities, and Inpatient & Outpatient services billed with a hospital provider number with a primary or secondary diagnosis of 290-319.)
• Radiology (only includes services billed under a radiologist provider number)
• Services Provided by Schools and Head Start Programs

**(Any provider who receives a referral from the ED for follow up treatment must receive authorization from the PCP)

Key Program Resources

1. N.C. Division of Medical Assistance, Managed Care Section, phone number (919-647-8170). A toll free phone number is available for current or potential Medicaid recipients. Calls are answered by a team of Customer Service Representatives. The number is 1-888-245-0179. When corresponding by mail to the managed care section, send correspondence to:
   
   Division of Medical Assistance
   Managed Care Section
   2501 Mail Service Center
   Raleigh, NC 27699-2501
   If you know the name of the person to whom you are trying to correspond, please put your letter to the attention of that person.
   
   
2. Regional Managed Care Consultants
   
   
3. Basic Medicaid Billing Guide
   
   
4. Carolina ACCESS Monthly Dual Eligible Status Reports
   
   
5. Carolina ACCESS Monthly Enrollment Reports
   
   
6. Carolina ACCESS Monthly Exemption Report by County and Type
   
   
7. Automated Voice Response (AVR) system (1-800-723-4337)
   
   
8. Recipient Handbooks available in English and Spanish
   
   

Updated December 19, 2007