Unlocking PHP Incentives in 2026: What NC Practice Managers Need to Know Now

January 28, 2026 — Practice Support Team

North Carolina’s Medicaid environment is shifting rapidly — and with those changes come new opportunities for practices to strengthen quality performance, support patient outcomes, and secure incentive‑based reimbursement. Whether your practice works with AmeriHealth Caritas, Healthy Blue, WellCare, UnitedHealthcare, or Carolina Complete Health, understanding both the current incentives and the upcoming 2026 standardized model is essential.

This post brings together key details from the major PHP programs — including Healthy Blue’s Healthy Rewards Program — along with insights from NC AHEC practice support coaches across the state. Our goal is simple: Help your practice claim every dollar it’s eligible for in 2026.

Why Incentives Matter More Than Ever

Medicaid PHP incentives directly support two major goals:

• Improving quality and outcomes by encouraging completion of evidence‑based preventive and chronic‑care services.
• Strengthening practice sustainability through reimbursement tied to performance and measurable care gaps closed.

One example is Healthy Blue’s Healthy Rewards Program, where members earn incentives for completing priority services such as:

• Prenatal and postpartum care
• Well‑child visits (0–30 months and 3–20 years)
• Breast, cervical, and colorectal cancer screening
• Diabetes A1c testing
• Immunizations
• Dental visits
• Tobacco cessation counseling
• Asthma medication adherence

When your practice completes these services and submits timely claims, patients earn rewards — and your practice earns quality credit and incentive payments.

What’s Changing in 2026 — and Why Preparation Matters

Beginning in 2026, NC Medicaid will implement the new Standardized AMH Performance Incentive Program. This statewide model will:

• Use one statewide set of AMH quality measures
• Standardize attribution and payment methodology
• Align performance periods and reporting timelines
• Eliminate PHP‑specific variations that burden practices
• Simplify workflows for multi‑plan practices

This new model will simplify your work — but only if your practice prepares before the 2026 performance year begins.

Insights From NC AHEC Practice Support Coaches

Across NC AHEC regions, practice support coaches continue to hear the same themes:

1. Practices want clarity as Medicaid rules evolve.

Coaches help translate changing guidance, sharing up‑to‑date measure specifications and actionable workflows.

2. Practices that align workflows early see stronger results.

Teams that adjust scheduling, documentation, and billing processes early consistently outperform late adopters.

3. Many practices don’t realize they’re missing out on incentives.

AHEC coaches frequently uncover unclaimed incentive opportunities during dashboard reviews or chart audits.

4. Practices that partner with AHEC early adapt more smoothly.

Coaches help practices translate policy into practical workflows — from interpreting 2026 measures to troubleshooting billing issues.

Action Steps for NC Practice Managers

Here’s what your practice should begin doing now:

1. Review all PHP incentive programs and align workflows.
   Confirm staff understand which services are incentivized and how to document them correctly.
2. Submit claims promptly.
   Incentive payments and quality credit depend on timely, accurate submission.
3. Educate patients about available rewards.
   Engaged patients complete more visits and help close more care gaps.
4. Prepare staff for the statewide 2026 program.
   Design your strategy to adopt unified documentation and coding processes.
5. Use your data.
   If you're unsure how you're performing, AHEC coaches can help review dashboards, attribution reports, or claims histories.

NC Medicaid PHP Patient Incentive Program Comparison (2026)

Including Healthy Blue, AmeriHealth, Carolina Complete Health, WellCare, and UnitedHealthcare

This comparison highlights:

• Whether each PHP has a real incentive program
• The reward model
• Reward amounts
• Annual caps
• QI‑relevant categories (WCVs, maternity, screenings, chronic disease, behavioral health)

• Streamline billing and paperwork processes.
• Enhance direct provider support.
• Improve the overall efficiency of Tailored Plan operations.

1. Review the New Contract: Trillium is asking providers to sign a new Procurement Contract for Provision of Services. This can be signed quickly via DocuSign.
2. Watch for Outreach from Andros: Trillium has partnered with Andros, a network management firm, to facilitate this transition. If you haven't already, expect to hear from them regarding contract amendments.
3. Educational Resources: If you want a deeper dive into these changes, we recommend watching the Trillium Essentials - Section 1 video, which provides a walkthrough of these updates.

North Carolina Medicaid is entering a major new chapter. Carolina Complete Health (CCH) and WellCare of North Carolina will officially merge into a single statewide health plan on April 1, 2026. The new combined plan will operate under the Carolina Complete Health name and will serve all six NC Medicaid regions.

As your Northwest AHEC Practice Support Team, we’re here to break down what this means for your practice, your teams, and—most importantly—the North Carolinians you care for.

Why This Merger Matters

This transition creates North Carolina’s largest Medicaid health plan, covering more than 775,000 members across the state. The unified plan continues as a Provider-Led Entity (PLE)—meaning North Carolina physicians retain a central governance role.

For practices, this means:

• Continued emphasis on provider voice in decision-making
• Streamlined processes under one statewide plan
• Reduced administrative duplication across CCH and WellCare products

Key Implementation Details You Need to Know

📅 Effective Date

April 1, 2026, unless NC DHHS issues updated guidance.

What This Means for Your Medicaid Patients

For current WellCare members

• Automatically transitioned to Carolina Complete Health
• No change in Medicaid benefits
• Will receive a new Member Welcome Packet and Member ID card
• Most members will keep their current primary care provider

For current Carolina Complete Health members

• Coverage expands statewide from 3 to 6 regions
• No change in Medicaid benefits
• New CCH Member ID card will be mailed as part of annual re-card
• Patients may keep their existing PCP

For Non-Members

Carolina Complete Health offers a free solution for payment by Electronic Funds Transfer (EFT) and Electronic Remittance Advice (835)/Explanation of Payment (ERA/EOP) through PaySpan®. If you are not already registered, create a new account by registering at payspanhealth.com or calling 1-877-331-7154, option 1.

For CCH providers

 The public website will remain https://network.carolinacompletehealth.com/. WellCare providers should begin using this webpage upon go-live (anticipated to be 4/1/2026) for updated materials (i.e. provider and billing manuals, contacts, and provider tools). 

What This Means for Your Practice

1. Contracting & Network Participation

• If your practice is contracted with either CCH or WellCare, you will remain contracted with the merged entity.
• To eliminate redundancy, the Medicaid product under WellCare agreements will be terminated as of April 1, 2026.
• Providers will continue serving:
  • Medicaid & Tailored Plan members through the CCH agreement
  • Medicare members through the WellCare agreement

If you received termination notices tied to the Medicaid product, these apply only to the WellCare Medicaid portion—not your overall WellCare contract.

2. Member Reassignment & Market Share

CCH has clarified:

• The new entity is not expected to exceed the market share cap
• Providers should not see large-scale member panel reassignment due to the merger

3. Billing, Claims & EFT/ERA

Frequently asked questions from providers include:

• EFT/ERA services will continue uninterrupted
• Claims for dates of service before April 1, 2026 will follow the originating agreement (CCH or WellCare)
• Claims on or after April 1, 2026 will process under the new CCH statewide plan

Updated provider manuals, billing guidance, and operations details will be posted on the official merger site as the go-live date approaches.

Operational Steps You Should Take Now

✔ Verify provider directory listings

Ensure your practice’s information is correct across:

• CCH Provider Directory
• WellCare Provider Directory

✔ Educate front‑desk and billing teams

Key items to emphasize:

• New member ID cards
• How to verify eligibility during the transition
• Which plan to bill based on date of service

✔ Review your contracts

Look specifically for:

• CCH agreement terms
• Any Medicaid-product termination notices from WellCare
• Tailored Plan participation details (if applicable)

✔ Monitor value-added service changes

Both CCH and WellCare note modifications coming to value-added services for 2026.

What Stays the Same

• Medicaid benefits for members
• Primary care provider assignments
• Commitment to provider-led governance
• NC Medical Society and NC Community Health Center Association remain partial owners of the Provider Led Entity (PLE)

Resources for Practice Managers

Here are the most relevant resources for keeping your team prepared:

Provider Merger FAQ (CCH Network Site)
https://network.carolinacompletehealth.com/merger.html

Member Merger Information (Public Site)
https://www.carolinacompletehealth.com/merger.html

Provider Services Contact:
1‑833‑552‑3876
NetworkRelations@CCH-Network.com

What are the trends in AI use in health care settings?

A recent JAMA article examines AI use in health care since 2023, and compares the changes in health care settings to wider AI use trends.

To learn more, check out the ADL’s January 15 Highlighted Resource: Adoption of Artificial Intelligence in the Health Care Sector

NC Medicaid has announced important updates to coverage for Psychiatric Collaborative Care Management (CoCM) services, effective December 31, 2025. This change impacts both NC Medicaid Direct and NC Medicaid Managed Care programs.

Key Update: End-Dating of HCPCS Code G0512

The Healthcare Common Procedure Coding System (HCPCS) code G0512 will be end-dated on Dec. 31, 2025. This means Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) must transition to reporting CoCM services using individual CPT and HCPCS codes that previously comprised G0512.

Per Centers for Medicare & Medicaid Services (CMS) guidance, the following codes should now be used:

• 99492 – Initial psychiatric collaborative care management, first 70 minutes in the first calendar month.
• 99493 – Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities.
• G2214 – Initial or subsequent psychiatric collaborative care management, first 30 minutes in a month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified healthcare professional.
• 99494 – Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month (up to four 30-minute sessions allowed per month).

Why This Matters

This update ensures alignment with CMS requirements and supports accurate reporting for CoCM services. Providers should review their billing practices and update systems to reflect these changes before the effective date.

Background

This bulletin serves as an update to the Sept. 17, 2025 bulletin on Psychiatric Collaborative Care Management coverage. NC Medicaid continues to emphasize integrated behavioral health care and collaborative models to improve patient outcomes.

Action Steps for Providers

• Discontinue use of G0512 after Dec. 31, 2025.
• Begin reporting CoCM services using codes 99492, 99493, 99494, and G2214.
• Ensure billing staff and systems are updated to comply with these changes.

For more details, visit the official NC Medicaid blog:
https://medicaid.ncdhhs.gov/blog/2025/12/30/updated-coverage-psychiatric-collaborative-care-management-december-30-2025

We’re excited to share a major development for rural health in North Carolina. Last week, the Centers for Medicare & Medicaid Services (CMS) approved North Carolina’s application for the Rural Health Transformation Program (RHTP)—a milestone that brings over $213 million in the first year to strengthen health care across our rural counties.

What Does This Mean for Your Practice?

• Significant Investment: The RHTP will support nearly 3 million rural North Carolinians and strengthen more than 400 rural health facilities statewide.
• Collaborative Approach: Implementation will involve state agencies, rural providers, community partners, academic institutions, and the private sector. This is a true team effort to improve health outcomes and care delivery.
• Governance and Regional Hubs: Once funding is received, NCDHHS will quickly establish a statewide governance structure and begin building regional hubs. Stakeholders—including practices like yours—will be engaged in funding and implementation decisions.

Get Involved: Virtual Town Hall

NCDHHS is hosting a virtual town hall to share program goals, next steps, and the anticipated statewide impact:

• Date: Friday, Jan. 16
• Time: 2:30–3:30 p.m.
• How to Join: Register using this link to attend via Zoom. You can also submit questions and join the RHTP mailing list during registration.

Why This Matters

• Expanded Resources: Expect new opportunities for funding, technical assistance, and collaboration to address rural health challenges.
• Practice Voice: Your input is needed! Participation in the town hall and ongoing engagement will help shape how resources are allocated and programs are implemented.
• Stay Informed: For updates and more information, be sure to opt in for the mailing list when using the registration link above.

Next Steps for Practice Managers

• Share this update with your teams and rural partners.
• Register for the town hall and encourage your staff to participate.
• Prepare questions or topics you’d like addressed—your feedback is essential.
• Watch for further communications from NCDHHS and our coaching team as implementation details emerge.

Happy New Year, North Carolina Practice Managers and Staff!

As we begin 2026, the landscape of childhood immunizations is shifting—bringing both confusion and opportunity for clarity. The latest update from the CDC, following a Presidential directive to align U.S. recommendations with “peer nations” like Denmark, has resulted in significant changes to the recommended vaccine schedule for children. Here’s what you need to know, and how to support your teams and families through this transition.

What’s Changed?

• Fewer Routine Vaccines: The CDC now routinely recommends vaccines for 11 diseases instead of 17. For example, the HPV vaccine moves from a 2-dose to a 1-dose schedule.
• Risk-Based & Shared Decision-Making: Several vaccines previously recommended for all children are now either:
  • Recommended only for high-risk groups: RSV (for children whose mothers didn’t get the pregnancy vaccine), Hepatitis A, Hepatitis B, Meningococcal.
  • Left to “shared clinical decision-making” (SCDM): Rotavirus, COVID-19, Influenza, Hepatitis A, Hepatitis B, Meningococcal. This means clinicians and families decide together, based on individual risk and benefit.
• No Change for Pediatric Vaccines Coverage: Medicaid and Prepaid Health Plans (PHPs) have not changed their position—coverage for pediatric vaccines remains unchanged at this time.

New HHS Childhood Immunization Schedule (Released January 5, 2026)

Key Points for Your Practice

1. Access Remains: Families can still access the full range of childhood immunizations recommended by the American Academy of Pediatrics (AAP) and American Academy of Family Physicians (AAFP). The AAP schedule remains unchanged and is available .
2. No Out-of-Pocket Cost: All vaccines—including those now under SCDM—are still covered with no out-of-pocket cost by ACA-regulated private insurance, Medicaid, and the Vaccines for Children (VFC) program. HHS has affirmed this commitment.
3. Evidence Is Unchanged: The scientific evidence supporting the full AAP and AAFP vaccination schedules remains robust. These changes do not reflect new safety or efficacy concerns.
4. Anticipate Challenges: Expect confusion and operational challenges around school vaccine requirements, clinical workflows, and supply of combination vaccines. Clear communication and updated workflows will be essential.

Practical Guidance for Practice Managers & Staff

• Continue to Offer and Recommend Vaccines: Pediatricians and primary care teams can still offer vaccines according to the evidence-based U.S. schedule. Parents can request them, and clinicians should reassure families about continued access and coverage.
• Update Clinical Workflows: Integrate prompts and education into EHRs and point-of-care tools to maintain routine vaccination workflows and avoid missed opportunities.
• Communicate Clearly: Use talking points that focus on health outcomes (illnesses prevented, hospitalizations avoided) rather than the number of vaccines. Emphasize that fewer vaccines does not mean better health outcomes.
• Monitor for Policy Updates: Stay tuned for further guidance from NC Medicaid, VFC, and state health agencies. Forward any updates you receive to the NC Immunization Coalition (NCIC) and share with your teams.
• Educate Staff and Families: Address misconceptions proactively. For example:
  • The U.S. is not an outlier—most peer nations have schedules similar to ours, not Denmark’s.
  • The broader U.S. schedule exists to fill gaps in healthcare access and disease screening.
  • The Hep B birth dose is a critical safety net, especially given gaps in maternal screening and follow-up in the U.S.
  • Combination vaccines help reduce the number of shots, not the level of protection.

North Carolina Secures $213 Million to Transform Rural Health Care

We’re excited to share a major milestone for rural health in North Carolina. The Centers for Medicare & Medicaid Services (CMS) has approved North Carolina’s application for the Rural Health Transformation Program (RHTP), unlocking over $213 million in first-year funding to strengthen health care delivery across 85 rural counties.

This achievement reflects collaboration with more than 420 stakeholders, including rural hospitals, community health centers, local health departments, Tribal communities, and community- and faith-based organizations. It underscores North Carolina’s long-standing commitment to ensuring rural residents have access to high-quality, affordable care.

Why This Matters

North Carolina has the second-largest rural population in the nation, facing unique challenges in access, workforce, and infrastructure. The RHTP introduces six key strategies to address these needs:

• Expand behavioral health services
• Invest in the rural health workforce
• Improve prevention and chronic disease management
• Support providers transitioning to value-based care
• Enhance health care technology
• Launch NC ROOTS Hubs to connect medical, behavioral health, and social supports

What’s Next

Implementation will involve a broad coalition of state agencies, rural providers, community partners, academic institutions, and the private sector. Once funding is received, NCDHHS will:

• Establish a statewide governance structure
• Begin building regional hubs
• Engage stakeholders in funding and implementation decisions

To keep the conversation going, NCDHHS will host a virtual town hall on Friday, Jan. 16 to share program goals, next steps, and statewide impact. Details and registration will be available soon on the https://www.ncdhhs.gov.

Impact at a Glance

• Nearly 3 million rural North Carolinians supported
• More than 400 rural health facilities strengthened
• $213 million in federal investment for year one

This is a transformative moment for rural health in North Carolina, and we look forward to working together to make it a success.

Would you like me to make this more conversational and blog-friendly (with a warm tone and call-to-action), or keep it formal and policy-focused for professional audiences?

Welcome to Your 2025 Wrapped

If 2025 were a playlist, it would be an epic mix of resilience, innovation, and hard work. As we close out the year, we wanted to take a moment to look back at the "music" we made together.

This year, practice managers and staff across our region didn't just keep the rhythm—you set the tempo for better healthcare in Northwest North Carolina. From navigating complex payer changes to launching new care models, you turned challenges into chart-topping successes.

Here is what your year sounded like, according to the numbers.

📊 The "Minutes Listened" (Our Impact by the Numbers)

You were incredibly busy this year. While much of the healthcare world was just tuning in, you were logging serious hours to improve access and quality.

• Total Practice Coaching Encounters: 2,297
  • That represents nearly 2,300 specific touchpoints where we worked side-by-side with you to solve problems and improve care.
• Top Region on the Charts: Ashe County ⛰️
  • Ashe County was our "Top Artist" this year with 164 encounters, proving that rural health remains the heartbeat of our region.
• The Rising Hits:
  • Alleghany and Alexander counties also topped the setlist, keeping the momentum strong across our footprint.

🎹 Your Top Genre: Medicaid Managed Care

If 2025 had a main genre, it was definitely Medicaid Managed Care.

Just like in previous years, this was the beat driving most of our work. Whether it was deciphering the Standardized Performance Incentive Program or navigating Advanced Medical Home (AMH) tier support, you stayed in sync with the state's biggest changes.

Your Top Sub-Genres (Trending Topics):

• Billing & Coding: The technical solos that kept your revenue cycle moving.
• Practice Management Operations: The daily rhythm of running an efficient office.
• Quality Payment Program (QPP): The critical performance reviews that ensured you got credit for your quality care.

💿 The "Viral Hits" (Top Stories of 2025)

Every year has those standout tracks that everyone talks about. These were the success stories and resources that defined 2025 for our network.

• The Story: Facing a surge in mental health needs, the team at Twin City Pediatrics implemented the Collaborative Care Model (CoCM).
• The Result: By June 2025, they didn't just launch—they became revenue-positive six months ahead of schedule. It was the feel-good hit of the summer and a blueprint for others to follow.

 The Indie Favorite: Fall Risk Assessment 

• The Story: Released in June, the self-paced course Falls: Screening, Risk Assessment and Care Planning became an instant essential for clinicians working with older adults.
• The Vibe: Since its debut on 6/16/25, it has racked up 223 registrations. By focusing on the STEADI framework, you proved that keeping patients safe and steady is a timeless classic that never goes out of style.

• The Story: With the announcement that the Clear Pricing Project ends on Dec 31, 2025, we shifted focus to transition planning.
• The Shift: You worked hard to prepare for the move away from CPP and into new fee schedules for 2026, ensuring your practices remain financially stable during the switch.

🔮 Your "Musical Aura" for 2026

Based on your listening habits late in the year, 2026 is shaping up to be a year of Innovation & Resilience.

We are already queuing up tracks on AI in Clinical Decisions, Cybersecurity, and leveraging the newly relaunched NC AHEC Digital Library. The setlist for next year is going to be exciting, and we can't wait to explore it with you.

Thank you for a chart-topping 2025!

Here’s to keeping the beat going in the New Year.

— The NW AHEC Practice Support Team

Need help planning your 2026 playlist? Reach out to us at practicesupport@wakehealth.edu.

We’re excited to invite you to the last Community Health Worker (CHW) Integration Workgroup meeting of the year on:

📅 Date: Tuesday, December 9, 2025
🕑 Time: 2:00 – 3:00 p.m.
📍 Location: Virtual (Zoom)

This session will feature El Futuro, sharing their experience implementing the Collaborative Care Model (CoCM) program with CHWs. It’s a great opportunity to learn from their journey and explore strategies for integrating CHWs into care teams.

Join Zoom Meeting:
https://us02web.zoom.us/j/89721245320?pwd=vZahdMsTNgYvfumrx08NsjzpnFPyKn.1
Meeting ID: 897 2124 5320
Passcode: 758973

Questions Contact Jessica Rodriguez at jessica.rodriguez@mahec.net.

Looking Ahead to 2026

This workgroup series will continue next year, highlighting CHW integration efforts across the state. Stay tuned for more opportunities to connect, share, and learn!