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Medicaid Transformation

Learn more hear about how Medicaid transformation is changing the way public healthcare is provided in North Carolina.

In 2015, the NC General Assembly enacted legislation directing DHHS to transition Medicaid and NC Health Choice from fee-for-service to managed care. Under managed care, the State contracts with insurance companies, which are paid a predetermined set rate per enrolled person to provide all services. The Department was on track to go live February 1, 2020; however, new funding and program authority were required from the General Assembly to meet this timeline and Medicaid Managed Care was suspended in November 2019. In July 2020, legislation authorized the restart of Medicaid Managed Care transformation efforts with a July 1, 2021 launch date for Standard Plans and a July 1, 2022 launch date for Behavioral Health I/DD Tailored Plans.

Alliance will also provide updated information in the Provider News Service. Providers can sign up for and see the most recent newsletter.

Medicaid Transformation Resources

What is a Standard Plan?

There are six health plan contracts, five prepaid health plans and one primary care case management entity, to deliver Standard Plan Medicaid services starting July 1, 2021, to eligible North Carolina beneficiaries.

AmeriHealth Caritas of North Carolina – Prepaid Health Plan; Statewide
Blue Cross and Blue Shield of North Carolina – Prepaid Health Plan; Statewide
UnitedHealthcare of North Carolina – Prepaid Health Plan; Statewide
WellCare of North Carolina – Prepaid Health Plan, Statewide
Carolina Complete Health, Inc. – Prepaid Health Plan, Regions 3, 4 and 5
Eastern Band of Cherokee Indians (EBCI) Tribal Option – Primary Care Case Management managed by the Cherokee Indian Hospital Authority. For federally recognized Tribal members and others eligible for services through the federal Indian Health Service agency.

What is a Tailored Plan?

North Carolina will launch specialized managed care plans, called BH I/DD Tailored Plans, starting in 2021. These plans are designed for those with significant behavioral health (BH) needs and intellectual/developmental disabilities (I/DDs). BH I/DD Tailored Plans will also serve other special populations, including Innovations and traumatic brain injury (TBI) waiver enrollees and waitlist members. Often this is called the “high risk” population.

Alliance Health was awarded a contract to operate a BH I/DD Tailored Plan beginning July 1, 2022.

How to find Standard Plan/Tailored Plan Status of Members

Providers can use NC Tracks to verify members’ eligibility and plan eligibility and Managed Care enrollment through the NCTracks Recipient Eligibility Verification function available in the Provider Portal.

Real-time eligibility verification method:

  • Log into the NCTracks Provider Portal.
  • Follow the Eligibility > Inquiry navigation.
  • Populate the requested provider, recipient, and time period information; Please use the effective date July 1, 2021, or after.

Questions? Contact the NCTracks Call Center at 800-688-6696.

This page was last reviewed for accuracy on 07/06/2021