Medicaid services are delivered primarily through a primary care case management (PCCM) program that is supported by Community Care of North Carolina (CCNC), which has a contract in place with the North Carolina Division of Medical Assistance (NC DMA, state Medicaid agency). Through this contract CCNC does not bear any risk, as NC DMA still pays for all Medicaid services provided by CCNC. CCNC delivers services through patient-centered medical homes, and has 14 distinct non-profit networks across the state. These networks consist of providers, practices, local health departments, and community resources. There were a total of 1,488,263 beneficiaries enrolled in North Carolina’s Medicaid program as of July 2011. Of these, 1,238,563 were enrolled in managed care.
Community Care of North Carolina is operated under a 1932(a) State Plan Amendment and an Affordable Care Act Section 2703 Health Homes for Chronic Conditions State Plan Amendment.
The North Carolina Division of Medical Assistance provides both EPSDT and Health Check services to Medicaid eligible children. Together, Health Check and EPSDT provide for the complete care of children and youth in Medicaid. Mental health, dental and substance abuse services are integrated into the services provided by the CCNC primary care providers, and are coordinated by designated Health Check Coordinators.
North Carolina has adopted the Federal definition of medical necessity, and the state’s EPSDT Policy Instructions elaborate further and define the term “Ameliorate”:
“EPSDT services include any medical or remedial care that is medically necessary to correct or ameliorate a defect, physical or mental illness, or condition [health problem]. This means that EPSDT covers most of the treatments a recipient under 21 years of age needs to stay as healthy as possible, and North Carolina Medicaid must provide for arranging for (directly or through referral to appropriate agencies, organizations, or individuals) corrective treatment the need for which is disclosed by such child health screening services. “Ameliorate” means to improve or maintain the recipient’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. Even if the service will not cure the recipient’s condition, it must be covered if the service is medically necessary to improve or maintain the recipient’s overall health.”
|Initiatives to Improve Access
|Reporting & Data Collection||
Community Care of North Carolina (CCNC) maintains an Informatics Center in connection with the Division of Medical Assistance (DMA), the Office of Rural Health and Community Care (ORHCC), and the Centers for Medicare & Medicaid Services (CMS). The Informatics Center contains health care claims data provided by Medicaid and includes a Case Management Information System that is used by the CCNC care managers to help coordinate the care of Medicaid recipients, including children (for more information see Care Coordination).
North Carolina, via the DMA and ORHCC, was awarded $9.2 million dollars to work on three of the five categories of the CHIPRA Quality Demonstration Grant. North Carolina’s CHIPRA grant will experiment with new and existing quality measures for children, promote health information technology as a tool for the delivery of care to children, and create and evaluate models that will improve the delivery of care while demonstrating impact on health, quality, and cost.
In North Carolina an EPSDT medical screening exam should include a developmental level and mental health assessment. Services including therapy (physical, occupational, and speech/language), rehabilitation, in-home care, substance abuse, and in-home care services, are all covered by EPSDT if needed to correct or ameliorate a child’s health problem.
|Support to Providers and Families||
Support to Providers
Community Care of North Carolina (CCNC) has case managers in all 100 counties in that state, these managers help the networks and practices coordinate care (for more information see Care Coordination). CCNC also has a provider toolkit that includes a number of pediatric tools.
Support to Families
North Carolina Division of Medical Assistance (DMA) staffs Health Check Coordinators that families can contact for information about Health Check and EPSDT services. North Carolina DMA has also partnered with the North Carolina Healthy Start Foundation, which maintains a website with information on Health Check.
Care Coordination is a critical element of Community Care of North Carolina’s (CCNC) Medical Home model. CCNC describes its medical home as a place to receive preventive and sick care; and where patients have continuous relationships with providers; and where patients have enhanced access; and have access to care coordination services. The CCNC networks provide care coordination services for their patients, including children.
The primary form of care coordination provided by the networks is population management to support practices, which includes: customized reports, patient assessment and care planning, and medication management. CCNC also has case managers present in all 100 counties in the state.
North Carolina Medicaid makes fee-for-service payments to the providers in the networks for the services they deliver to enrollees. In addition, both primary care providers and the networks receive per member per month (PMPM) payments to pay for care coordination services.
North Carolina has several other initiatives related to Care Coordination for children including:
||Dental care, including preventive and restorative care, is on a list of services that can be covered by EPSDT if needed to correct or ameliorate a child’s health problem. As of April 1, 2014, a new contractor (CSC) is assuming responsibility from the Division of Medical Assistance for prior approval requests of certain EPSDT services including dental and orthodontic services.|