Network Provider FAQs

A:  The General Assembly passed legislation in 2015 that will transform our state-operated, fee-for-service Medicaid program into a new program that will rely on three (3) prepaid health plans to administer Medicaid benefits statewide and (1) provider-led plan to administer Medicaid benefits in Regions 3 and 5, Carolina Complete Health (CCH)

A:  Carolina Complete Health will be the prepaid health plan that, if awarded, will hold the Medicaid managed care contract with the State and be a licensed insurer in North Carolina.  Carolina Complete Health Network is an organization that will be governed and owned by North Carolina physicians, be responsible for activities including provider relations and quality improvement for the health plan, CCH.  CCHN will also take the lead in developing the medical coverage policies that will be adopted and implemented by CCH.  Both CCH and CCHN will be parties to the provider participation agreement with physicians and other providers that join the network.

A:  We believe the individuals who care for Medicaid patients should lead the direction and operations of CCH. A majority of CCH’s board of directors and the medical policy committees will be comprised of physicians that participate in the plan. In addition, the Carolina Complete Health Network will co-own CCH with Centene (one of the largest Medicaid MCOs in the country).  CCHN will itself be owned by North Carolina physicians, physician assistants and nurse practitioners, the North Carolina Medical Society, and the North Carolina Community Health Center Association. We are unaware of any other model that allows for provider leadership and ownership the way this one does.

A:  No, having an ownership interest in Carolina Complete Health Network should not raise self-referral concerns for physicians who treat Carolina Complete Health patients or refer those patients for services.

The federal physician self-referral law (known as “the Stark law” or “Stark”) generally prohibits a physician from referring Medicare and Medicaid patients to an entity that furnishes designated health services when the physician or a member of the physician’s immediate family member has a financial relationship with the entity, unless an exception applies.  Under Stark rules, CCHN is not an entity that furnishes or delivers health care services or supplies to patients.  CCHN exists primarily to enhance the quality of the health care services that its contracted physicians and other health care providers provide to Carolina Complete Health patients, and not to deliver or provide those services itself.

A:  Both will have operations based in North Carolina with local service centers, leadership teams, and representatives to assist North Carolina providers and Medicaid patients.

A:  The PPA with your practice/facility includes a provision that allows you to cancel the agreement at any time with one hundred twenty (120) days’ notice.  

A:  Yes, the PPA includes financial incentives that could allow primary care physicians to earn more than the Medicaid fee schedule. In addition, the reimbursement provisions in the agreement allow for adjustments to be made to reimbursement and financial incentive programs if applicable, once the state completes the actuarial rate setting process.

A:  Insurance company solvency rules require health plans to maintain large sums of capital reserves to cover claims, liabilities and to protect patients. For NCMS and NCCHCA, these rules meant a capital partner was necessary.  In addition, both organizations wanted a partner that brought expertise in Medicaid and health plan operations to the table.

A:  With the goal of having the opportunity to shape healthcare delivery for North Carolina Medicaid patients and physicians/providers/facilities under the new program, the North Carolina Medical Society completed a rigorous selection process, interviewing a number of potential capital and risk-bearing partners.  Based on the selection criteria, Centene was chosen.