North Carolina is a state full of opportunities to provide quality care to diverse individuals. As of May 8th, 2024, there are over 158,000 Medicaid Beneficiaries over the age of 65 residing in the state of North Carolina.
There are an additional 293,000 individuals who qualify for Medicaid benefits due to a disability. Medicaid does not just cover these individuals’ annual visit to their primary physician, or their annual tooth cleaning, but a laundry list of services provided by In-Home supportive care providers throughout the state.
Programs are available through several different payers to ensure that Medicaid beneficiaries have the highest quality of life regardless of social status.
The state NCDHHS (North Carolina Department of Health and Human Services) offers home care services through the Aging and Disabled waiver programs to those individuals over the age of 65, as well as younger disabled individuals through plans like CAPC and CAPDA.
North Carolina Managed Care Organizations
Many providers we encounter are unaware, though, that NCDHHS is not the only Medicaid payer in the state of North Carolina.
There are an additional five Managed Care Organizations, or MCOs, in the state that have been delegated the task of care coordination and payment facilitation for a large portion of the state's Medicaid beneficiaries.
In fact, nationwide, approximately 80% of Medicaid Beneficiaries are receiving their homecare benefits through some sort of MCO, MCE, or LME, and not their respective state program.
For providers seeking to gain access to this population of potential clients, they will typically require that you hold a contract with the state plan first.
North Carolina Managed Care Organizations:
- Amerihealth Caritas
- Carolina Complete Health
- Healthy Blue North Carolina
- United Healthcare Community Plan of North Carolina
- Wellcare
Local Management Entities
In addition to these 6 aforementioned payers, there are an additional four Local Management Entities responsible solely for the case management of behavioral health/IDD cases. These LMEs, like the MCOs, are responsible for certain districts predetermined by the state.
These LMEs include:
So, what is it like to provide services to Medicaid clients in the state of North Carolina?
Electronic Visit Verification (EVV)
EVV or Electronic Visit Verification is a necessary technology to ensure the reduction of fraud and waste within the Medicaid homecare industry. Introduced in the 21st Century Cures Act, states have been charged with selecting a system that will track 6 points of data for every in-home visit:
- Type of service provided
- Individual receiving the service
- Individual providing the service
- Date of service
- Location of service (typically GPS)
- Service start and end times
North Carolina is classified as an “Open EVV Model State”. This means, that although the state has selected an EVV aggregator, providers can use whichever scheduling software they’d like, if it can build an EDI connection (Integrate) to their EVV aggregator.
Through this EDI connection, all EVV information will be transmitted from the scheduling software of their choice to the respective aggregation system that the payer has selected.
North Carolina Department of Health and Human Services (NCDHHS)
Working with the state program you will be introduced to several systems you may not have used before.
Sandata has been selected as the EVV aggregator for the state, and providers will need to acquire a login to their state portal system. This is provided for free to contracted agencies looking to provide in-home supportive care.
All EVV data will be sent to the state through Sandata, but claim data requires a separate system for submission. The billing portal that providers will encounter is called NCTracks. This is where providers will not only have the ability to enter and track their claim data, but also receive their authorizations for new clients.
Managed Care Organizations/Local Management Entities
All Managed Care Organizations (MCOs) and Local Management Entities (LMEs) have chosen HHAeXchange as their Electronic Visit Verification (EVV) aggregator.
This means that regardless of the number of payers you work with, you will only need to use one HHAeXchange system to manage your interactions with them.
HHAeXchange’s state portal functions as a comprehensive aggregation system where providers can receive new authorizations, enter shift data, and submit claims for payment.
If a provider chooses to use a third-party EVV system for scheduling, they must still submit all shift and claim information to the state via the EDI connection with their HHAeXchange portal.
Use Paradigm
If you're an active provider looking for some assistance with back-office tasks, please reach out by filling out the contact us form on our website or the form that appears below this article. We look forward to working with agencies throughout the state to ensure quality care for those who need it.
About the Author: Lincoln has spent over 6 years working in the homecare industry, starting with a direct role at a homecare agency working with in-group homes for developmentally disabled adults. He then spent 2 years working with providers from the Midwest to the East Coast helping them through the implementation of EVV mandates specifically in Minnesota, North Carolina, and New Jersey. He now serves as an Account Executive at Paradigm, helping providers credential with government payers to help them reach their goals, as well as assisting in back-office optimization to ensure they reach their full potential.
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