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Medicaid Transformation Q&A for Members

Cardinal Innovations Healthcare — August 15, 2019
In July 2019, representatives from Cardinal Innovations Healthcare held a series of town hall meetings with members and families across its 20-county service area. In those town hall sessions, we answered a number of questions asked by our members. We have compiled the questions we received from our members in those sessions and our responses in this article.
 

What is Medicaid transformation?

North Carolina’s Medicaid program is in the process of system-wide reform, often referred to as Medicaid transformation, which will move most Medicaid benefits to a managed care model. Behavioral health benefits have been operating under a managed care model in North Carolina’s Medicaid program since 2011, managed by entities like Cardinal Innovations, otherwise known as Local Management Entities/Managed Care Organizations (LME/MCOs). Under Medicaid transformation, people who qualify for Medicaid will now have most of their health benefits, including physical, behavioral, and pharmacy benefits, managed by one Medicaid health plan.
 

What are standard plans and tailored plans? Are they the same as NC Managed Care?

NC Medicaid Managed Care plans, also known as “standard plans,” are health plans that will cover physical, behavioral, and pharmacy benefits for the majority of Medicaid enrollees under Medicaid transformation. Five companies will contract with the NC Department of Health and Human Services (DHHS) to offer NC Medicaid Managed Care plans starting in November 2019. To learn more and compare plans, visit ncmedicaidplans.gov.
 
Tailored plans, known today as LME/MCOs, will offer additional behavioral health services not available through NC Medicaid Managed Care standard plans. Most people who get services for behavioral health needs, substance use disorders (SUDs), intellectual or developmental disabilities (IDD), or traumatic brain injuries (TBI) today through LME/MCOs will continue to receive their services through NC Medicaid Direct and then tailored plans when they become operational.
 
On July 1, 2021, after meeting readiness reviews with NC DHHS, LME/MCOs will become “tailored plans” and will administer physical, behavioral, and pharmacy benefits for the parts of the Medicaid population with the most complex behavioral health and IDD needs.
 

How do I know which plan I am enrolled in?

The NC Department of Health and Human Services (DHHS) is mailing letters explaining which plan or plans you may qualify for and if there are options available to you. What you receive from DHHS and when you receive it depends on which county you live in and which plan(s) you qualify for.

If you are eligible for a Standard Plan, you may have received an enrollment packet in July or the first week of September. Coverage will begin in all regions on February 1, 2020. Some members may have received an “exempt” letter indicating that no action was required, and some members may not have received a letter at all.

Open enrollment for Standard Plans through NC Medicaid Managed Care will begin October 14, 2019 for all 100 counties in North Carolina. The best way to check your status is to contact the enrollment broker at 1-833-870-5500.

 

Who is enrolled in which plan?

You will remain with your LME/MCO through NC Medicaid Direct and then be enrolled in a tailored plan when they become operational in 2021 if any of the following apply:
  • You receive services through the Transitions to Community Living Initiative (TCLI) program
  • You are on the NC Innovations Waiver
  • You are on the Registry of Unmet Needs (Innovations waitlist)
  • You receive Medicaid services for a traumatic brain injury (TBI)
  • You have a diagnosis of a Severe Mental Illness (SMI), Severe and Persistent Mental Illness (SPMI), and/or a Severe Substance Use Disorder (SUD) and have received an enhanced service in the last 18 months
  • You are Medicaid eligible and also receive state-funded behavioral health services
  • You have had two or more inpatient hospitalizations or emergency room visits for psychiatric or substance use disorder treatment in the last 18 months 
Most other Medicaid enrollees would be covered by a Standard Plan through NC Medicaid Managed Care, which consists of four statewide and one regional health plan. The best way to check your status is to contact the enrollment broker at 1-833-870-5500.
 

What do I need to do to make sure I stay with my LME/MCO?

Until 2021, you can get enhanced services for behavioral health, IDD and TBI support needs from your LME/MCO. To continue to get these services, you must stay in NC Medicaid Direct until tailored plans launch in 2021. If you enroll in NC Medicaid Managed Care, you may not be able to get your behavioral health, IDD or TBI services. NC Medicaid Managed Care does not include many of the services that LME/MCOs offer. To check your status, contact the enrollment broker at 1-833-870-5500.
 

What if I am the legal guardian but my child or family member is living independently and receives an enrollment letter?

All enrollment and exempt letters should be mailed to the legal guardian. If you are concerned that you haven’t received a letter, please contact the enrollment broker at 1-833-870-5500. If you are not the legal guardian, and your child or loved one receives services through Cardinal Innovations today, they can discuss any letter they receive with their provider or care coordinator to help them understand their choices.
 

What is the role of local Departments of Social Services (DSS) in this process?

Each of North Carolina’s 100 counties has a DSS office that is in charge of Medicaid enrollment and eligibility – this will not change under Medicaid transformation. DSS will provide Medicaid eligibility information to the state on an ongoing basis, and the state will use that information to review needed services and determine eligibility. The Standard Plan enrollment broker, Maximus, has provided training and information to DSS offices around the state.
 

Does enrollment follow where you live or the county where you get Medicaid from?

Medicaid eligibility and enrollment comes from your Medicaid county of residence, which may not always be the same as where you live or receive services.
 

What is the auto-enrollment process?

If you are only eligible for standard plan benefits through NC Medicaid Managed Care, you will be able to choose from four or five health plans, depending on where you live. If you don’t choose a plan on your own during open enrollment, the state will choose one for you.
 
However, if you receive benefits through an LME/MCO today, and are auto-enrolled into a standard plan, you may be able to request to stay with your LME/MCO, or tailored plan when they become operational in 2021. To discuss your enrollment options, contact the enrollment broker at 1-833-870-5500.
 

Who does the enrollment broker work for?

The enrollment broker, Maximus, is a third-party entity contracted by DHHS to help members understand their choices and choose the correct plan. More information can be found at www.ncmedicaidplans.gov or by contacting them at 1-833-870-5500.
 

What if a member is enrolled in a Standard Plan but wants to stay with their LME/MCO or suddenly needs services that aren’t available in a Standard Plan?

If you are auto-enrolled into a standard plan through NC Medicaid Managed Care but would like to remain with your LME/MCO, you must complete a Health Plan Change Request form within 90 days of enrollment. That form will be sent to DHHS for review. If you are assigned to an LME/MCO through NC Medicaid Direct, but would like to enroll in a standard plan through NC Medicaid Managed Care, contact the enrollment broker at 1-833-870-5500. Outside of the 90-day window following your enrollment, you can still transition to an LME/MCO in the middle of a plan year if you require certain crisis or enhanced services not available through NC Medicaid Managed Care plans.
 

What is the process when a member requests to transfer between standard and tailored plans? Who assesses the forms?

We are still awaiting final guidance from DHHS as to the exact process for transitions, as well as how requests will be reviewed. Final guidance should include details on due process once a request to move between plans is requested by a member, a provider, or admitting facility.
 

If a member is receiving enhanced services and meets the criteria to remain with their LME/MCO, but is auto-enrolled in a standard plan, does the Health Plan Change Request form still need to be completed?

Yes, the Health Plan Change Request form must still be completed. There is a form for members that can be completed by the member, guardian or care coordinator, as well as a form for providers.
 

Who can help me with the Health Plan Change Request form?

A provider can help document your needs on the Health Plan Change Request form and your guardian, family member or Cardinal Innovations care coordinator can help you complete the form.
 

I am a parent of multiple children. What if one receives services that are coordinated by the LME/MCO and one doesn’t?

If you have a child receiving specialty services such as Innovations, IDD, enhanced behavioral health or substance use disorder services through an LME/MCO, they should continue to receive services exactly as they are now. If other family members do not utilize these specialty services and they qualify for Medicaid, they will be enrolled in a standard plan through NC Medicaid Managed Care. Contact the enrollment broker at 1-833-870-5500 to discuss the options available for your family members and available services on each plan.
 

Can an individual or family choose a new LME/MCO as part of the enrollment process?

No. Plan choice is currently only available if you are enrolling in a standard plan through NC Medicaid Managed Care. Enrollees in NC Medicaid Managed Care will have a choice between four statewide and one regional plan.  People who receive services through the LME/MCO system will continue to be assigned a plan based on geography.
 

What happens to exempt members once the standard plans go live?

If a member is exempt from enrollment in a standard plan, their behavioral health benefits will continue to be administered by their LME/MCO, and Medicaid physical and pharmacy benefits will remain fee-for-service until July 2021, when the LME/MCOs transition to tailored plans. Tailored plans will manage physical, behavioral, and pharmacy benefits for members.
 

What happens to individuals who receive behavioral health, substance use or IDD services from state funds or other non-Medicaid services?

You will continue to receive services in the same way you do now, and will not take part in the enrollment process.
 

What is happening to Innovations members?

If you receive services through the NC Innovations Waiver, you are supposed to automatically remain with your LME/MCO. If you or your family member receive Innovations Waiver services and receive an enrollment packet, please contact the enrollment broker immediately at 1-833-870-5500. Any Innovations member that enrolls in a standard plan, either by accident or by choice will lose their Innovations Waiver slot and related services. In order to avoid any disruption, we recommend members and families connect with their care coordinator or provider to ensure that they are in the right plan.
 

What is happening with members on the Registry of Unmet Needs?

If you are on the Registry of Unmet Needs, also known as the Innovations waitlist, and are not receiving (b)(3) services, it is possible that you could choose or become automatically enrolled in a standard plan. Our current understanding is that enrolling in a standard plan does not change your place on the Registry of Unmet Needs waitlist. If you are currently on the waitlist and receiving (b)(3) or state-funded services, and want to continue those services, you must remain with your LME/MCO. In order to avoid any disruption, we recommend members and families connect with their care coordinator or provider, or call the enrollment broker at 1-833-870-5500 to ensure that you are in the right plan.
 

What happens to homeless individuals who may have Medicaid?

If they are receiving services, the best option would be to connect with their provider to understand what plan they are assigned to.
 

What if a member needs foreign language assistance?

Any member who receives an enrollment or eligibility letter should receive it in their preferred language. The enrollment broker has materials and translators available for 15 languages, listed at the bottom of their website at www.ncmedicaidplans.gov, or by calling 1-833-870-5500.
 

What happens to my Social Security Disability?

If you have questions about your Social Security Disability, contact your county Department of Social Services.
 

What is happening with (b)(3) services?

The (b)(3) services are additional Medicaid services outside of the NC Medicaid state plan available for eligible people with mental health conditions, IDD, and/or substance use disorders. Currently, (b)(3) and state-funded services are only available through LME/MCOs and can only be received through providers contracted with the LME/MCOs. If you or your family member currently receive (b)(3) services, and you receive an enrollment letter for standard plans, you may complete the Health Plan Change Request form to stay with your LME/MCO and continue receiving (b)(3) services.
 

What if Medicaid is my secondary insurance?

Your private insurance will continue to cover the same benefits it does today. Depending on the Medicaid services you or your family member receive, you may be exempt and remain with your LME/MCO, or be eligible to enroll in a standard plan through NC Medicaid Managed Care. Contact the enrollment broker at 1-833-870-5500 to understand which type of plan you are eligible for.
 

How many providers have signed up to contract with the standard plans?

We do not know the answer to this question. Contact your provider directly to see which health plans your provider is contracted with.
 

How many people involved in Medicaid transformation, including the creation of processes and documents, are parents?

We do not have this information. DHHS regularly conducts webinars and listening sessions with and for consumers. More information can be found at www.ncdhhs.gov.
 

How many parents are on the Cardinal Innovations Board?

Three representatives from our Consumer and Family Advisory Committees (CFACs) serve on our 19-member Board of Directors. CFACs are comprised of members and family members and advise LME/MCOs on things like service gaps, underserved groups and community issues.  
 

Will children involved in foster care and juvenile justice be enrolled in standard plans or will they remain with the LME/MCOs and eventually be enrolled in a tailored plan?

Our understanding is that as of now, all children in the foster care system with behavioral healthcare needs will remain with the LME/MCOs. DHHS has referenced the possibility of developing a specialty plan to manage the unique needs of children in the foster care system, however, details have yet to be released.
 

What is going to happen to my care coordinator?

Your care coordinator is staying with your LME/MCO. In DHHS’ long-term plan, Level 3 Advanced Medical Homes and Care Management Agencies will provide some Care Management. You will have a choice in that process, and we will communicate more details when we know more. Our focus right now is making sure care coordination team members have the right skills and experience needed to manage integrated care for our members.

View or print Q&A here.


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Updated on September 17 due to changes in the Medicaid open enrollment extension

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