Sarah Jagger, JD, MPH
Former Vice President of Operations
The North Carolina Department of Health and Human Services (NC DHHS) continues to prepare for a December 1, 2022 roll out of the Behavioral Health and Intellectual / Developmental Disabilities (I/DD) Tailored Plan (Tailored Plan).
There are several moving parts that must be understood and deadlines and requirements that providers must closely monitor and act on to ensure that they are prepared for go-live in December.
That then is the purpose of this article – to provide a quick definitional run down of the Tailored Plans and key aspects to help North Carolina providers evaluate contracting strategies and decisions. This is particularly timely because, while December may feel a long time down the road, one key date is coming up very quickly – July 16, 2022 – providers must have executed contracts with Tailored Plans to be included in the initial beneficiary choice period.
WHAT IS A TAILORED PLAN VERSUS A STANDARD PLAN?
It is important to first understand how the Tailored Plans differ from Standard Plans. Standard Plans are contracted health plans that offer integrated physical health, pharmacy, care coordination and basic behavioral health services to qualifying Medicaid beneficiaries in North Carolina. They are called Standard Plans because they refer to the standard population needs. In this way they are distinct from populations, like those that may have complex Behavioral Health diagnoses, or Long-Term Services and Supports needs, which the State has carved out of the general population for more targeted (or ‘tailored’) service delivery.
Tailored Plans must provide their beneficiaries with the same physical health, behavioral health, certain long-term services and supports, and pharmacy benefits as the Standard Plans; they must also provide services that serve individuals with significant behavioral health conditions, I/DDs, and traumatic brain injuries (TBI) as well as people utilizing state-funded services.
Tailored Plans will ensure the delivery of integrated care to individuals with significant behavior health needs and I/DDs as well as other special populations including Innovations and Traumatic Brain Injury (TBI) waiver enrollees and waitlist members.
In addition, Tailored Plans will be responsible for managing the state’s non-Medicaid (state-funded) behavioral health, developmental disabilities and TBI services for uninsured and underinsured North Carolinians.
While this distinction appears to be cut and dry given the Plans will be serving different populations, the relationship between Standard Plans and Tailored Plans is complicated due to the state law that requires Tailored Plans to contract with a Standard Plan in order to “meaningfully leverage PHP expertise to support and strengthen BH I/DD Tailored Plan capabilities to ensure readiness and ability to manage all applicable aspects of the Contract.” NC DHHS refers to this relationship as a partnership.
Under this partnership, among other things, Tailored Plans may leverage the Standard Plan’s existing provider network as its own. This is why North Carolina providers have likely received notices of amendment from PHPs they have contracted with in the past few weeks, or, alternatively a provider contracted with a Standard plan will receive a referral to the Standard Plan partner (Tailored Plan) to discuss the participation in the Tailored Plan’s network.
Under this leveraged network structure, a provider may be given the option to add the Tailored Plan program network to its existing network participation agreement for the Standard Plan program. As such the provider may not need a new, separate contract with the Tailored Plan. This is a streamlined option, that removes the hassle of contract negotiations, but it also removes the benefit and opportunity of contract negotiations for providing care for a population that may have very distinct needs and operational requirements.
Tailored Care Management providers include Care Management Agencies (CMAs), who deliver behavioral health, substance use, and/or intellectual and developmental disability services and care management, or Advanced Medical Homes (AMH+) who deliver both primary care services and tailored care management services.
WHAT DOES THIS DEADLINE MEAN FOR MY ORGANIZATION?
A guiding principle of Medicaid managed care is that beneficiaries must have a choice of providers. To operationalize this for go-live, NC DHHS will provide beneficiaries an enrollment period or beneficiary choice period. During this period, beneficiaries will have the opportunity to choose their primary care provider (PCP) and their Tailored Care Management provider. For the Tailored Plan program, this period will take place between August 15, 2022 – October 14, 2022.
For health plans to have enough time to process provider contracts and ensure that provider records are properly loaded and transferred to NC DHHS, providers’ contracts with health plans must be signed and mailed to the Tailored Plans by July 16, 2022.
If providers are not contracted by this time, NC DHHS cautions that you may risk losing patients. As beneficiaries will be choosing their PCP and Tailored Care Management provider from those who are contracted as of July 16.
It is important to note that this is not the only opportunity to be included in-network with the Tailored Plans. Those beneficiaries that do not select their provider by the end of the initial beneficiary choice period (October 15) will be automatically assigned (auto-assigned) to a PCP and Tailored Care Management provider. Providers who miss the July 16th deadline can still be included in auto-assignment if they are contracted by:
- September 15th for PCPs
- September 30th for Tailored Care Management providers
While it is important to consider these timelines and risks as part of your contracting strategy, one should do so from an informed perspective. Therefore, I offer the following data to help quantify the risk and opportunity for providers. During the initial beneficiary choice period for roll out of the Standard plans in 2021, only 14% of the total eligible population actively selected their provider. That means 86% of the beneficiary population were automatically enrolled into a health plan in which their current PCP was in-network. And if you look around the country at Medicaid auto-assignment, the statistics from NC align with rates in many other states.
The NC DHHS expects Tailored Plans to negotiate with any willing physical health services or pharmacy services provider in good faith; they may only exclude eligible providers from their physical health services or pharmacy services networks if the provider refuses to accept network rates. However, NC DHHS has granted Tailored Plans the authority to maintain a closed network for behavioral health, I/DD and TBI services. Such providers may be excluded from their behavioral health, I/DD, or TBI networks if it has a sufficient network of providers of that type.
I, therefore, recommend that providers actively work to contract with plans by the July 16th deadline; however, I caution against rushing the negotiation process simply to enter the initial beneficiary choice pool. As it is the September deadline that carries more weight given the high rate of auto-assignment and it is critical that the contract reflects terms that you can achieve.
WHAT DO I NEED TO CONSIDER WHEN EVALUATING TAILORED PLAN CONTRACTS AND AMENDMENTS?
In the very short-term, providers should be receiving contracts for the Tailored Plans, as well as amendments from the Standard Plans, given the intersection between these two. You will want to begin evaluating these as soon as possible.
Things to consider at the outset of this evaluation process:
- What % of your population falls under a Tailored Plan?
- Does this % merit the cost of contracting (or including in your Standard Plan terms)
- Whether you want to participate in the Tailored Plan contracting:
- Do the services required align with your business plan (if you don’t have one we strongly suggest that you develop one to facilitate strategic decision making)?
- Does the opportunity to serve this population balance with the operational requirements and changes that your organization will have to implement?
- Do you have adequate staffing to serve this population?
Evaluation of the contract should be conducted methodically with attention to each of the individual terms and how they align with your current operations or would changes be required. Our experience supporting providers in the Standard Plan contracting process suggests that much of the detail will be incorporated by reference in the provider manual; meaning the contact refers to another document (provider manual, policy, etc.) outside of the contract thus making it part of the contract. So, you will need to dig into these documents (after first requesting them from the health plan), and not just rely on the terms of the contract, to truly understand the operational expectations.
Because many providers are already contracted with the Standard Plans, participating under the Tailored Plan will be presented as an amendment to your existing contracts. Therefore, if you do not object to the amendment in the time stated you are deemed to have accepted (so calendar the deadline as you evaluate!).
If you need support in evaluating contracts or amendments or negotiating terms of these with the Standard Plans or Tailored Plans or any other contracts for your organization, please reach out to Atrómitos today. We have deep expertise in contract review, negotiation, and operations.