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NC Medicaid 1115 Waiver Approved

Tuesday, October 30, 2018

Last Wednesday, the Centers for Medicare and Medicaid Services (CMS) announced approval of North Carolina’s 1115 Waiver, which requested modifications to the way our state runs its Medicaid program. The approval gives NC the authority to implement a Medicaid managed care program according to the timeline and structure proposed by the NC Department of Health and Human Services (DHHS).

Key Aspects of the NC Medicaid Waiver Program include:

  1. Behavioral Health Integration: Mild to moderate behavioral health services will be available through Standard Plans. Individuals needing more intensive BH services shall elect Tailored plans which launch in year 2 of managed care. There will be a specialized behavioral health home model for beneficiaries with complex needs and seamless coordination with physical health care services.
  2. Opioid Strategy: The program intends to Increase access to inpatient and residential services for individuals struggling with opioid and substance use addiction.
  3. Healthy Opportunities Pilot: The program will include a pilot focused on improving health and reducing health care costs in 2-4 regions of the state that will address some/all of five priority areas impacting health: unstable housing, food insecurity, transportation issues, employment challenges and interpersonal safety.

Aspects of the 1115 Waiver that were NOT approved:

  • Uncompensated Care pool for tribal providers due to high burden of uncompensated care borne by the Cherokee Indian Hospital Authority. (NC DHHS still in consultation with CMS)
  • Workforce demonstration. NC was not approved to fund loan repayment and recruitment bonuses for critical Medicaid provider types. CMS recommends doing a study to determine the need and submit a demonstration after the gaps and level of need is identified.
  • Behavioral health home capacity building funds. CMS did not approve funding for capacity-building funds, but the BH care management model with tailored plans was approved.
  • Telemedicine innovation fund was not approved.
  • Wrap around payments to safety-net providers to cover difference between PHP reimbursement and provider costs was not approved. (Note: This has no impact on FQHC/RHC Medicaid payments.)
  • Carolina Cares. This bill proposed in the NC General Assembly (NCGA) would extend Medicaid coverage to working adults with incomes at or below 138% of the federal poverty level. CMS made no determination on this item because it must first be passed into law by the NCGA before the federal government will review it.

This blog post from CMS Administrator Seema Verma outlines the NC Medicaid 1115 Waiver and its innovations.

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