By Robert Kurzydlowski
In 2017, there were 120,099 births in North Carolina [1]. Over half (55%) of those births were by mothers who received prenatal care and delivery services, or just delivery services, reimbursed by Medicaid [2]. North Carolina’s Division of Health Benefits currently pays for these and all eligible physical health services on a fee-for-service basis directly through payments to enrolled providers and health systems.
However, North Carolina’s new model for Medicaid, Medicaid transformation [3], will soon be a reality. On February 4th, 2019, DHHS announced statewide contracts with four commercial Managed Care Organizations (MCOs) and one Provider Lead Entity (PLE) that will be operating in two Medicaid regions [4]. The prepaid health plans (PHPs) these payers will offer are still going to provide the aforementioned physical health benefits and services, but now at a fixed amount per enrollee.
A result of this change is an evolution of care for women utilizing maternity services. Two Medicaid programs will evolve with Medicaid Transformation. Core maternity services, including medical care through a pregnancy medical home and care management, will still be covered, but the names of these programs will change. First, Pregnancy Medical Homes (PMHs) are becoming Pregnancy Management Programs (PMPs). Second, the Obstetric Care Management Program (OCMP) is becoming the Care Management for High-Risk Pregnancy Program (CMHRP).
Additionally there are some notable process changes to be aware of in these programs. The first is that PHPs will be required to report use of the state-created risk assessment tool and rate of post-partum follow up to the Division of Health Benefits. PHPs may, therefore, be more motivated to work with providers and care managers to assure high rates of screening and follow up. Secondly, during the transition period to managed care, PHPs will initially have to continue to offer Local Health Departments the right of first refusal in managing this care. However, after this transitional period PHPs will be able to negotiate care management with providers of choice – this could be with Local Health Departments or other care management providers.[5]
Some providers have raised concerns about increasing administrative complexity from five new payer entities [6]. Nevertheless, now that the transformation is set to occur, understanding these changes will provide for the most efficient and effective transition for all stakeholders. It is with this notion in mind that the NCIOM has been sure to consider this evolution in Medicaid care for women using maternity services in our newly formed task force: Developing a Perinatal System of Care for the state of North Carolina.
[1] https://schs.dph.ncdhhs.gov/schs/births/matched/2017/medicaid.html
[2] Id.
[3] https://nciom.org/what-is-medicaid-transformation/
[4] https://www.ncdhhs.gov/news/press-releases/dhhs-announces-prepaid-health-plan-contracts-medicaid-managed-care
[5] https://files.nc.gov/ncdma/documents/Medicaid/Provider/LHD-Medicaid-Tranformation-Slides-vfinal.pdf
[6] https://ncmedicaljournal.com/issue/5317