As the NC Title V Program is housed in the WCHS, and the WCHS Chief is responsible for administering both the Title V Program and the other federal and state programs located in the five Branches, the Title V Program’s relationship with other MCHB investments (e.g., SSDI, MIECHV, ECCS, ODH, EDHI, etc.) and other federal investments (e.g., WIC, Immunizations, etc.) is very strong. Through the SMT weekly meetings and other opportunities, the Title V Director is updated on plans and activities of the Branches to work with partners. The weekly DMT meetings provide an avenue for the WCHS Chief to partner with administrators of other HRSA programs and other programs within the NC DPH. The NC Association of Local Health Directors (NCALHD) meets monthly and includes committee meetings (such as the Maternal and Child Health, Care Management, and WIC Committee) which are held in collaboration with staff members from WCHS and other DPH Sections and enable the Title V Program to work collaboratively with NCALHD on matters that pertain to all LHDs. WCHS staff members, particularly the Regional Nurse, Social Work, Immunization, and Nutrition Services Consultants, also visit the LHDs regularly to perform monitoring and consulting duties and to provide technical assistance.

As highlighted in the needs assessment, WCHS also collaborates on a number of activities with several professional organizations in the state, many non-profit advocacy groups, schools of public health and medicine in NC, and many other organizations. WCHS and NC DHHS are involved in many statewide collaborations to address maternal, perinatal and child health.

The NC DHHS houses the state’s Medicaid, Mental Health/Developmental Disabilities/ Substance Abuse Services, and Social Services/Child Welfare programs, so within the management structure of DHHS, interagency coordination is expected and facilitated between the Title V Program and those programs. A copy of the current Inter-Agency Agreement between the state’s Medicaid agency and the Title V program is included in this application. Additionally, the DPH is signatory to a formal written agreement with the Division of Vocational Rehabilitation (assumes responsibility for Supplemental Security Income eligibility determination). The WCHS and its programs also collaborate with the Division of Public Instruction (DPI); Office of Rural Health; and Division of Child Development and Early Education. The WCHS also collaborates with the Department of Insurance closely on the ACA and the Department of Corrections around incarcerated parents and other issues. WCHS will continue to collaborate with other state agencies and partners to support DHHS’ Early Childhood Action Plan.

Legislation to transform and reorganize NC’s Medicaid and NC Health Choice programs was passed in September 2015. On June 1, 2016, NC’s Medicaid Reform Plan (Section 1115 demonstration) application was submitted to the federal Centers for Medicare & Medicaid Services (CMS) after three years of stakeholder engagement and planning. As part of the reform process, the state’s Medicaid team and partners within DHHS held a dozen public hearings across the state to collect feedback from the public, including health care providers, patients, beneficiaries, and advocates. In all, nearly 1,600 people attended the public hearings. Additionally, written comments were received from 750 citizens during the public comment period. The demonstration will test and evaluate five broad-based initiatives and their program proposals: 1) Build a System of Accountability for Outcomes; 2) Create Person-Centered Health Communities; 3) Support Providers through Engagement and Innovations; 4) Connect Children and Families in the Child Welfare System to Better Health; and 5) Implement Capitation and Care Transformation through Payment Alignment.

During the spring of 2017, Secretary Cohen and DHHS requested public input to help determine whether modifications were needed to the Section 1115 wavier. Public input sessions were held in four locations across the state during May 2017 and written comments via email were also requested. In August 2017, DHHS released a detailed proposed program design for transforming the state Medicaid and NC Health Choice programs from a fee-for-service system to a managed care system. Providers had a chance to review and comment on the document prior to the November 20, 2017 submission to CMS by DHHS of an amendment to the original Section 1115 demonstration waiver application to CMS. Per the November 20, 2017 DHHS public notice, the amendment was submitted to “strengthen the design of its managed care program to ensure the State’s ability to: 1) measurably improve health, 2) maximize value to ensure the sustainability of the program, and 3) increase access to care.” The notice goes on to say, “As described in the Proposed Program Design, NC is proposing initiatives to achieve those goals, including designing managed care products tailored for enrollees with high behavioral health needs, strengthening the provider workforce through new initiatives specially designed to address the needs of the Medicaid population, and testing and strengthening public-private initiatives in select regions of NC that aim to measurably improve health and lower costs through evidence-based interventions addressing targeted health-related needs.” Approximately 1.6 million of the current two million Medicaid beneficiaries will be mandatorily enrolled in managed care under the proposed demonstration. Members of NC’s only federally-recognized tribe – the Eastern Band of Cherokee Indians – will be permitted to opt-in to managed care and to disenroll at any time without cause.

On August 9, 2019, DHHS released the Request for Proposal (RFP) for Prepaid Health Plans (PHPs), and announced the contract award on February 4, 2019. The awarded contracts were to the following plans:

• AmeriHealth Caritas North Carolina, Inc.
• Blue Cross and Blue Shield of North Carolina, Inc.
• UnitedHealthcare of North Carolina, Inc.
• WellCare of North Carolina, Inc.
• Carolina Complete Health, Inc. (Regions 3 & 5 only)

Carolina Complete Health, Inc. is a provider-led entity that will not be available statewide, but should provide for some innovation and allow for some additional beneficiary choice in Regions 3 and 5. The PHPs will be subject to rigorous oversight to ensure that standards are being met, including development of strong networks, providing a full range of benefits with positive beneficiary experiences, and making timely payments to providers.

NC DHHS was on track to go live with Medicaid transformation on February 1, 2020. However, in November 2019, the NC General Assembly adjourned without providing the required new funding and program authority for the transition to managed care, thus enrollment and implementation for the transition to managed care was suspended on November 19, 2019. With Medicaid Managed Care suspended, NC Medicaid continues to operate under the current fee-for-service model administered by NC DHHS.

In June 2020, the NC General Assembly passed legislation that was signed into law by Governor Cooper on July 2, 2020 that mandates that Medicaid transformation happen by July 1, 2021; however, the final version of the bill took out penalties totaling about $20 million per month that would have been levied on NC DHHS had they missed that deadline for rollout. As noted by the Secretary when the transition was suspended, once suspended, the transition cannot easily or quickly be restarted, so the July 2021 timeline is quite aggressive, particularly given the additional burden placed on NC DHHS and providers to respond to Public Health Emergency COVID-19.

While exactly how NC Medicaid Managed Care will impact WCHS and the populations it serves is still unknown, the current plans for specific program elements that focus on pregnant women and young children include preserving aspects and strengthening current program models. While there are some changes for programs such as Pregnancy Medical Home (quality improvement and practice support for obstetrical providers), Obstetrical Care Management (case management for high risk mothers – medical and social), and Care Coordination for Children (medically complex children and those exposed to toxic stress), NC will continue with Pregnancy Management Program (PMP), Care Management for High-Risk Pregnancy (CMHRP), and Child Management for At-Risk Children (CMARC), respectively, with similar priorities and program activities. The differences between the current and new programs include changes in standard contract terms (e.g., LHDs will be required to coordinate with the PHP in cases where a woman/child has more than one care manager, and LHDs are required to accept referrals from the PHP for the CMHRP/CMARC program). In addition, LHDs will be required to contract with each PHP to provide care management services, LHDs will receive payments from PHPs, and LHDs will be required to share data with PHPs. PHPs will be required to offer LHDs the right of first refusal for the provision of CMARC and CMHRP for a transitional period of three years. Two advisory groups were launched in 2019 to make recommendations to improve outcomes.

The Behavioral Health and Intellectual/Developmental Disability (BH I/DD) Tailored Plan is scheduled to be launched in 2021, but, as a result of Public Health Emergency COVID-19, the Tailored Care Management certification process for providers interested in becoming Advanced Medical Home Plus (AMH+) practices or Care Management Agencies (CMAs) was suspended in June 2020. The BH I/DD Tailored Plan will serve individuals with more serious behavioral health disorders (serious mental illness, serious emotional disturbance, and/or substance use disorders), I/DDs, and traumatic brain injuries. Tailored Care Management will build on the Standard Plan care management model, but will be more intensive and customized. While the certification process has been suspended, NC DHHS released the Tailored Care Management Provider Manual and application questions in June 2020 to allow providers maximum time to understand requirements and begin preparing their applications. NC DHHS will announce the revised certification timelines well in advance of the application deadlines.

As part of the transition to Medicaid Managed Care, NC plans to launch Healthy Opportunity Pilots in two to four geographic areas of the state. These pilots will allow payers, providers, and community-based organizations to test evidence-based interventions designed to improve health and reduce cost by addressing housing instability, food insecurity, lack of transportation, interpersonal violence, and toxic stress for eligible Medicaid beneficiaries. Up to $650 million in state and federal Medicaid funding has been authorized for these pilots. A request for information (RFI) and policy paper on the Healthy Opportunities Pilots was released in February 2019 followed by several addenda along with public webinars seeking public input on considerations related to Pilot design and implementation. Lead pilot entities (LPEs) will serve as the essential connection between PHPs and human services organizations. The evaluation of the Healthy Opportunities LPE proposals was suspended in May 2020 as a result of NC DHHS’s response to the COVID-19 pandemic. A new award date has not yet been determined.

Another NC DHHS strategy to promote healthy opportunities and address social determinants of health was to build a statewide coordinated care network to electronically connect those with identified needs with community resources. Through a public-private partnership between NC DHHS and the Foundation for Health Leadership and Innovation, NCCARE360, a statewide technology platform was created connecting healthcare and human services. NC is the first state in the country to create such a network. NCCARE360 completed its statewide rollout in June 2020, six months ahead of schedule as the team fast-tracked the statewide expansion in response to COVID-19. Since the network launched in 2019, more than 1,000 organizations have joined and a repository of more than 10,000 local services can be accessed at https://nccare360.org/resources/. NCCARE enables health and community-based organizations to make electronic referrals, communicate in real time, securely share client information, and track outcomes together. The system has multiple functionalities including:

• A robust statewide resource directory powered by NC 2-1-1 that will include a call center with dedicated navigators, a data team verifying resources, and text and chat capabilities.
• A community repository powered by Expound to integrate multiple resource directories across the state and allow data sharing
• A shared technology platform powered by Unite Us that enables health and human services providers to send and receive electronic referrals, seamlessly communicate in real-time, securely share client information, and track outcomes.
• A community engagement team powered by Unite Us working with community-based organizations, social service agencies, health systems, independent providers, community members and more to create a statewide coordinated care network. (list taken directly from NCCARE360 website https://nccare360.org/about/, accessed 7/22/2020)

Initially, resource information has been concentrated around housing, employment, food assistance, interpersonal violence, transportation, no wrong door, and income support, but new verified resources are added daily. WCHS staff members, particularly regional consultants working with LHDs, will continue to promote the use of NCCARE360 by LHDs, community-based organizations, and other partners.