Medicaid Transformation About to Kick in to High Gear

Blog | January 30, 2019


By Berkeley Yorkery


Next week the North Carolina Department of Health and Human Services (NC DHHS) will announce which of the eight applicants for NC Medicaid Prepaid Health Plan (PHP) contracts have been selected to provide managed care services. Once the contracts are awarded, the selected PHP providers will have a lot of work to do to be ready by July 1, 2019, when they will begin enrollment for eligible individuals in phase I regions.


What Happens After Contracts are Awarded?


The PHPs selected will have to move quickly to meet the timeline laid out in the request for proposals.


Selected PHPs must submit their implementation plans to NC DHHS within 14 days of award of contract, followed by operational plans, member materials, various other policies and plans, and a PHP license from the NC Department of Insurance within 90 days.


PHP providers who do not currently operate in North Carolina or are newly created will have to hire staff. Each PHP is required to have a working call center based in North Carolina and to fill a number of staff roles within 90 days. Certain PHP staff must be licensed in North Carolina, while others are required to reside in North Carolina, including staff in the following areas:


  • Member services
  • Care management
  • Behavioral health staff
  • Housing Specialist
  • Transition Specialist
  • Complaint, grievance, and appeal coordinators
  • Provider relations and call center staff
  • Liaisons between the NC DHHS, the North Carolina Attorney General’s Medicaid Investigation Division, and the Division of Social Services
  • Tribal provider contracting specialists



Enrollment in PHPs


For individuals enrolled in Medicaid, information about coming changes to Medicaid enrollment will begin in earnest this spring. Maximus, the enrollment broker hired by NC DHHS, to “provide choice counseling, enrollment assistance and education to beneficiaries as they select from [the PHPs],[1]” may begin outreach to individuals enrolled in Medicaid once the contracts are awarded to PHPs on February 4, though it is expected that this outreach will begin later in the spring. In April (eight weeks after contracts are awarded) PHPs will be allowed to begin marketing their plans to potential enrollees.

PHPs are required to open enrollment for regions in phase I no later than July 19, 2019.[2] PHPs will begin delivering services in phase I regions on November 1, 2019. Open enrollment for the remaining regions of the state will begin no later than October 19, 2019, with PHPs delivering services beginning February 1, 2020.




[2] As part of Medicaid Transformation, the state is divided into six Medicaid regions. Two regions will be in phase I with the remaining four regions in phase II. ( NC DHHS has not announced which regions will be in phase I and II.