North Carolina Department of Health and Human Services in Partnership with Duke-Margolis Center for Health Policy

In a shift from fee-for-service to managed care, North Carolina began enrolling Medicaid beneficiaries into Prepaid Health Plans (PHPs) on July 1, 2021. PHPs cover physical health, behavioral health, and pharmacy services in return for a single capitated payment. While dual-eligible individuals are currently excluded from enrolling in PHPs, the North Carolina Department of Health and Human Services (NC DHHS) plans to implement a capitated program for this population that integrates Medicare and Medicaid benefits, including long-term services and supports, by 2024.

Project Purpose

With support from Arnold Ventures, the Duke-Margolis Center for Health Policy (Duke-Margolis) is working in collaboration with NC DHHS to identify options for developing an integrated care model for North Carolina and an implementation pathway that aligns with ongoing state Medicaid transformation efforts.

Project Approach

To achieve the project objectives, Duke-Margolis is using a phased, multi-component approach, including:  

• Convening an Advisory Panel and Engaging with NC DHHS and Stakeholders. Duke-Margolis is convening an Advisory Panel of 14 national, state, and local experts to inform analysis and policy development. In the first year of the project, the Advisory Panel will refine the project objectives and the specific focus areas. In the second year, the Advisory Panel will meet with local stakeholders to solicit input and feedback on the proposed policy options.
• Conducting Literature Review and Stakeholder Interviews. Duke-Margolis is conducting a targeted literature review and interviewing stakeholders from North Carolina and other select states that pursued integration through managed care pathways. The information gathered will help identify and explore key considerations for integration; state actions to implement and/or support integration and stakeholder involvement; key outcomes to monitor (e.g., access to coordinated care and quality of care, expenditures, health disparities); and success levers, challenges, and gaps associated with other state approaches to integration.
• Analyzing Linked Medicare and Medicaid Data. Duke-Margolis will link Medicare and North Carolina Medicaid claims at the beneficiary level to create longitudinal analytic data files for the dual-eligible cohort. Duke-Margolis will use the linked files to analyze dual-eligible beneficiaries’ demographic characteristics, eligibility categories, and chronic conditions, as well as their service utilization and total Medicare and Medicaid costs.
• Developing Policy Options for NC DHHS. Duke-Margolis will develop policy options for a pathway to Medicare-Medicaid integration in North Carolina. The Advisory Panel and local North Carolina stakeholders will discuss and provide feedback on the proposed policy options.

Support for Other States

Many states are in the same position as North Carolina — they know they want to improve care for their dual-eligible populations by providing fully-integrated programs, but face resource gaps that prevent them from moving forward. Arnold Ventures launched the Advancing Medicare & Medicaid Integration initiative to support states and help fill those resource gaps. Learn more about funding opportunities.