Community Care of North Carolina (CCNC)

Program Location: 
Raleigh, NC
Number of Practices: 
Payer Type: 
the state employee health plan
Blue Cross and Blue Shield of North Carolina
Medicare (through MAPCP)

Reported Outcomes


Community Care of North Carolina (CCNC) is a public-private partnership designed to create regional networks of primary care clinicians, hospitals, pharmacy, public health, social services and other community organizations to provide care based on the patient-centered medical home (PCMH). In this regional PCMH model, patients are partnered with a primary care provider who leads the health care team to address all of the patient's needs. The goals of CCNC is to:

  • Improve the care of Medicaid beneficiaries
  • Reduce costs of care 
  • Connect every Medicaid beneficiary with a medical home and community network of supports
  • Develop local systems that improve chronic condition management

CCNC encompasses many other medical home programs for the State including the Care Coordination for Children (CC4C) program, the Child Health Accountable Care Collaborative, Dual-Eligible program, Multi-payer Advanced Primary Care Practice program, and a Medicare Quality Demonstration Section 646 Waiver program, among others. Visit the CCNC Results website for a slide presentation on the CCNC medical home structure. 

In addition, CMS approved North Carolina's State Plan Amendment on 5/24/2012. North Carolina used the amendment to expand upon its existing Community Care of North Carolina (CCNC) medical home program. North Carolina offers Health Home services to Medicaid enrollees who: have two chronic conditions, or have one chronic condition and are at risk for developing another. In North Carolina, mental illness and substance abuse disorder are not considered to be qualifying chronic conditions.  

Each Community Care enrollee is linked to a primary care provider to serve as a medical home that provides acute and preventive care, manages chronic illnesses, coordinates specialty care and referral to social, community, and long-term care supports, provides comprehensive management, and provides 24/7 on-call assistance. 

**CCNC also participated in the MAPCP demonstration until 12/31/2014. 


Payment Model: 

State-level support for the medical home

  • Pays FFS (fee for service) at 95 percent of Medicare rates.
  • Pays a PMPM fee (initially funded through a 1915(b) waiver, and subsequently through a State Plan Amendment) directly to practices for their Medicaid enrollees ($2.50 pmpm, $5.00 pmpm for the aged, blind and disabled).
  • Pays a PMPM fee directly to the network for aggregate enrollment of participating practices ($3.00 pmpm, $5.00 pmpm for aged, blind and disabled).

2703 Health Homes payment model: 

North Carolina will receive a 90% enhanced FMAP (Federal Medical Assistance Percentage) for the specific health home services in Section 2703. The enhanced match does not apply to the underlying Medicaid services also provided to individuals enrolled in a health home. 
The 90% enhanced match is good for the first eight quarters in which the program is effective. North Carolina may receive more than one period of enhanced match, understanding that they will only be allowed to claim the enhanced match for a total of 8 quarters for one beneficiary. 

Fewer ED / Hospital Visits: 

State Auditor Report (August 2015) based on data from July 1, 2003, through December 31, 2012

  • ~ 25% reduction in inpatient admissions
  • Statistically significant reduction in readmissions, inpatient admissions for diabetes, and emergency department visits for asthma
  • No statistically significant effect on overall emergency department use

Population Health Management (September 2013)

  • In every year after the first year of evaluation (2007)  the rate of hospitalizations for Medicaid enrollees with a disability was significantly lower. Inpatient admission rates declined from 420 visits per 1000 patients in 2007 to 384 visits per 1000 patients in 2011. 
  • ED visits increased from 396 to 552 among unenrolled from 2007-2011.

Health Affairs (August 2013)

  • In a study of patients hospitalized during 2010–11, patients who received transitional care were 20 percent less likely to experience a readmission during the subsequent year
  • One readmission was averted for every six patients who received transitional care services and one for every three of the highest-risk patients.

North Carolina Medical Journal (January 2012) evaluation of CCNC medical home enrollees vs. non-enrollees in 2010

  • Statistically significant reduction in readmissions
  • Projections estimate, based on these findings, that CCNC will prevent more than 6000 additional admissions for the non aged, blind, or and disabled (ABD) cohort, and more than 4000 additional admissions for the ABD cohort
Improved Access: 

State Auditor Report (August 2015) based on data from July 1, 2003, through December 31, 2012

  • Approximately a 20% increase in physician services (increased physician services is expected to prevent more expensive health care in the future)

Population Health Management (September 2013)

  • ​Statistically significant increase in access to ambulatory physician services (2007-2011)
Cost Savings: 

 State Auditor Report (August 2015) based on data from July 1, 2003, through December 31, 2012

  • Savings of approximately $78 per quarter per beneficiary, approximately $312 a year in 2009 inflation-adjusted dollars (approximately a 9% savings)
  • CCNC saved the state Medicaid program about $134 million in 2009
  • 17.6% reduction in spending on inpatient admissions

Population Health Management (September 2013) data review 2007-2011 for non-elderly Medicaid recipients with disabilities

  • A model using a non-matched CCNC enrollment sample found:
    • statistically significant cost savings:
    • 2007: $190.91 PMPM (p<.0001)
    • 2008: $ 153.71 PMPM (p<.0001)
    • 2009: $117.54 PMPM (p<.0001)
    • 2010: $97.22 PMPM (p<.0001)
    • 2011: $63.74 PMPM (p<.0001)
  • This analysis estimates total cost savings of $184,064,611 for the first 4.75 years of the program; a 7.87% relative savings form the average PMPM cost.
  • A  model using a matched CCNC enrollment sample found: 
    • ​statistically significant cost savings: 
    • 2008: $52.54 PMPM (p=.005)
    • 2009: $80.75 PMPM (p<.0001)
    • 2010: $72.65 PMPM (p<.0001)
    • 2011: $120.69 PMPM (p<.0001)

North Carolina Medical Journal (January 2012) 

  • Medicaid spending for ABD eligible beneficiaries (nondual) enrolled in CCNC declined by $122 PMPM from FY2009 to FY 2011
    • despite the enrollment of higher-risk patients into the CCNC program during that period

Milliman Medicaid Cost Savings Report (Dec 2011)

  • Estimated cost savings of $382 million in 2010; 11% reduction in pharmacy costs; 25% reduction in outpatient care costs
  • An analysis by health care analytics consultant Treo Solutions found that CCNC saved nearly $1.5 billion in health care costs from 2007 through 2009.
Last updated January 2019
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