North Carolina Medicaid Transformation

Posted by The Arc of North Carolina

This blog series will address topics related to Medicaid Transformation to help answer questions and give you the most current information.

What is Medicaid Transformation?

In 2015, legislators passed a bill requiring that the North Carolina Department of Health and Human Services develop and implement a new Medicaid managed care program, with the goal being to control and limit rising Medicaid expenditures in our state budget, while improving overall care.

In the past, Medicaid services were set up as fee-for-service, meaning that if you went to the doctor, had tests done while you were there, or received medical equipment; there was a specific fee or price assigned to that medical service. The same is true for community support services funded by Medicaid. If you received a visit or a service from your support staff or had any residential or day services, there were specific fees for them.

In the plan for Medicaid Transformation, all Medicaid-funded medical services and community support services will eventually be capitated. In this “cap” all of the costs for the group of people receiving Medicaid-funded supports and services will be added together and an average cost per person will be calculated. This average cost per person will become a “per member per month” amount that is paid to a managed care organization to cover all Medicaid-funded services.

For most people with intellectual and developmental disabilities receiving Medicaid-funded services these changes will NOT take place until 2021.

If you are eligible for Medicaid now, you will still be eligible after these changes. If you make a copay when you get Medicaid-funded medical services, your copay amount will stay the same. If you receive NC Innovations waiver supports and services, nothing will change for now.

There has been a great deal of discussion regarding the changes coming to Medicaid in North Carolina. If you are an individual with intellectual and developmental disabilities and have Medicaid funding, you may be wondering what is happening and how you may be affected.

If you have questions regarding the services you receive or how Medicaid Transformation will affect you, contact your LME/MCO . You can also contact The Arc of North Carolina at 1-800-662-8706 or

Next Up: What’s the Difference Between the Medicaid Standard Plan and the Tailored Plan?

Click here for Medicaid Transformation Resources.