Medicaid Managed Care

Primary Care Case Management Program (PCCM)

The PCCM program (or Primary Care Provider program) is available as the Managed Care Program within the state. This program functions Statewide. Certain Medicaid populations are required to enroll in the PCCM program. Recipients either choose or are assigned to a Primary Care Provider (PCP). The PCCM program functions to provide adequate access to Primary Care; to provide coordination and continuity of health care services, to avoid duplication of services, to focus on delivering high quality, and to ensure efficient and effective health care services.

Any inquires regarding the programs of Primary Care Case Management (PCCM), ExperienceHealthND (Health Management), or the Program of all Inclusive Care of the Elderly (PACE) can be sent to the following mailbox: dhsmci@nd.gov

Recipient Information

The PCCM program requires all non-emergent health care services be received from your PCP. If you require specialty or hospital services, a referral from your PCP is required prior to the appointment. Some services do not require a referral. It is important to review the PCCM handbook. A listing of services and whether referral requirements are needed is listed within this handbook. If you have questions regarding this program, contact your County Case Worker or the ND Medicaid office.

Primary Care Case Management Handbook

This booklet describes ND Medicaid's Primary Care Case Management Program, copayment requirements, referral process, client responsibilities, and addresses commonly asked questions .

• Primary Care Provider Booklet (428 kb pdf)

List of Available Primary Care Providers - updated 4/25/2013

Primary Care Provider Information

Information regarding Managed Care can be found in the General Information for Providers Manual in the Managed Care Chapter.

• Primary Care Case Management Referral Guide
• Primary Care Case Management Referral Form
• Nurse Practitioner PCP Opt-in Letter dated November 30, 2009 ( kb pdf)

Health Management Program

Provider Information

Effective October 1, 2011, ND Medicaid began transitioning the North Dakota Medicaid disease management program to a Health Management program. Program services include patient-centered care coordination, telephone contact with a care coordinator or nurse within the clinic, involvement from a team of medical professionals as needed and patient education. Providers, pratitioners, clinics, or Disease Management Organizations (DMOs) may be eligible to provide additional health management services to certain, eligible ND Medicaid recipients with chronic diseases. The scope and criteria of the program is outlined within the Provider-based and DMO-based contracts below. Interested parties must submit a letter of intent followed by a description of how the health management team will meet the criteria as outlined in Scope of Service section of the contract(s) outlining geographic coverage area (county, city, etc.), and must be eligible to enroll or already be an enrolled ND Medicaid provider.

Inquires or comments regarding this Program may be sent to dhsmci@nd.gov.

Providers, Practitioners, Clinics:

• Supplemental Contract for Providers, Practitioners, or Clinics
• Attachment A - Reporting requirements (Providers, Practitioners, Clinics)
• Attachment B - Reports Format (Providers, Practitioners, Clinics)

Disease Management Organizations:

• Supplemental Contract for DMOs
• Attachment A - Reporting Requirements (DMOs)
• Attachment B - Reports Format (DMOs)

Appendix C - References for Health Management

North Dakota Medicaid Provider Enrollment

Medicaid Recipeint Information for Health Management

Certain Medicaid recipients may be eligible for Health Management services through their local Provider, Clinic or a Disease Management Organization. If you have been diagnosed with Asthma, Diabetes, Chronic Obstructive Pulmonary Disease, or Congestive Heart Failure, you may be able to received additional care coordiation services through your local provider, clinic, or a health management nurse within the state. Those inquiring about the program and its services may contact one of the Medicaid Health Management teams listed below.

Excluded populations include:

• Medicare coverage (dual eligible)
• Additional Major Medical Coverage
• Recipient Liability
• Resides in a Nursing Facility or Intermediate Care Facility for the Intellectually Disabled (ICF/ID)
• Enrolled with another Health Management Provider - you may be enrolled with only one health management provider at a time

This is a voluntary, free program. You may disenroll from the program at any time.

Current ND Medicaid Health Management team:

• ExperienceHealthND (Coverage area - Statewide)
  • Available toll-free at 1-866-435-4306

Correspondence:

• Recipient Correspondence - 9/27/2011 (40kb pdf)
• Provider Correspondence - 10/4/2011 (41kb pdf)

June 30, 2011 - The renewal for the 1915(b)(4) Managed Care Waiver was submitted to the Centers for Medicare and Medicaid Services (CMS). Listed below are the documents submitted.

• 1915(b)(4) Waiver (239kb pdf)

Program of All-Inclusive Care for the Elderly (PACE)

More detailed information regarding the PACE Program through ND Medicaid & Northland can be accessed by clicking the links below.

• Northland PACE Website
• PACE Fact Sheet (66kb pdf)

Managed Care State Plan

Section 4701 of the Balanced Budget Act of 1997 permits states to require medicaid beneficiaries to enroll with a managed care entity as a state plan option rather than through a 1915 waiver. The state plan was approved by Centers for Medicare and Medicaid Services (CMS) and was effective July 1, 2001. The files contain the state plan material as approved by CMS.

• Page 11 (8kb pdf)
• Managed Care SPA (7.32 MB pdf) approved and effective 12-1-2009

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