The Department of Health and Human Services (DHHS) is implementing a policy update related to Standard Plan oversight of providers performing delegated care management functions. Under the Standard Plan contract with the Division of Health Benefits, Standard Plans are required to achieve National Committee for Quality Assurance (NCQA) Health Plan Accreditation (HPA) by July 1, 2025.

The updated policy aims to minimize the impact of the health plan accreditation process on delegated care management entities by exempting providers participating in the following programs from being required to participate in health plan accreditation-related oversight:

  • Advanced Medical Home Tier 3 (AMH 3)
  • Care Management for At-Risk Children (CMARC)
  • Care Management for High-Risk Pregnancies (CMHRP)
  • Healthy Opportunities Pilots (HOP)
  • Integrated Care for Kids (InCK)

Under the policy, delegated care management providers cannot be required by Standard Plans to participate in audits or monitoring activities for the purpose of meeting certain NCQA requirements. With this policy in place, NCQA will not evaluate Standard Plans against delegation oversight requirements when Standard Plans delegate care management activities for the programs specified above, until further notice. This means that NCQA’s review of plan performance on the care management elements of accreditation will not use documentation from delegated care management providers, easing provider burden related to the plan accreditation process. DHHS is instituting this policy until Standard Plan NCQA health plan accreditation is complete in 2025, after which it may be extended or modified.

Standard Plans may continue to monitor delegated entities’ care management activities against other care management or program requirements (e.g., Advanced Medical Home care management requirements) to advance their performance expectations. Standard Plans and delegated care management providers are also encouraged to work in collaboration w to prepare for potential future NCQA delegation oversight or otherwise to improve care management performance or build care management capacity.

Details on the policy change can be found in Notice of Policy Changes Related to Standard Plan Oversight of Delegated Care Management. Additional information on the AMH program can be found on the NC Medicaid Advanced Medical Home webpage. [source]