Medicaid transformation details to arrive soon

Eufemia Didonato

Feb. 20—In early March, many of those who receive services through Medicaid, a federal program established to provide health care services for the impoverished, will be receiving a packet concerning future medical services.

Don’t throw it out, warned Ira Dove, the director of the Haywood County Health and Human Services Department.

The packet is the gateway to continued services under a new managed-care program being implemented by North Carolina.

The new program requires Medicaid recipients to choose one of four providers that will be operating in the county. If they fail to select one of the companies, they will automatically be enrolled in one of the four. It could well be that failure to do research on the front end could mean an individual won’t be able to continue seeing a regular doctor or patronize their existing pharmacy, Dove said.

By March 1, an enrollment broker, Maximus, will provide unbiased choice counseling and help individuals enroll in one of the programs. Legal Aid of North Carolina will provide ombudsman services through outreach activities, a public website and a toll-free phone number.

The state manages the federal Medicaid funds and hopes to increase efficiency by turning them over to insurance companies that will contract to manage Prepaid Health Plans (PHPs).

Medicaid beneficiaries can begin enrolling March 15, and must make their choice by May 15. Those who take no action will randomly be assigned a PHP.

In Haywood County, there are 14,917 individuals on Medicaid, but not all will transfer to a managed care program, at least not immediately. Dove expects 7,500 to 9,000 of this group to be signed up with a managed-care provider by July.

Major change

Currently, those with a Medicaid card merely present it when they go to the doctor, their pharmacy or the hospital where they get treatment or a service and the government is billed. Providers have long complained about the reimbursement rate, which they maintain is just a fraction of the actual costs — and one that’s well below the going rate for private-pay patients.

For the past several years, state leaders have worked to develop the managed-care program where five PHPs across the state will be contracting on a per-person basis to provide every healthcare service needed by the individuals who enroll in their program. Dove said there is no guarantee that every doctor, dentist, pharmacist or health service provider in the county has agreed to work with each managed-care company.

That’s why it will be important for those receiving managed-care enrollment packets to carefully review the plans being offered. Each plan will be a bit different, with different providers, different benefits and different services.

Each PHP will be paid a pre-determined rate for each person it enrolls, and that rate is supposed to cover the cost of all the services an individual needs.

The state’s vision for the Medicaid transformation is “to improve the health of North Carolinians through an innovative, whole-person-centered, and well-coordinated system of care that addresses both the medical and nonmusical drivers of health,” Dove told the Haywood County Board of Commissioners at its meeting on Monday evening.

The health and human service departments in each county will be charged with determining which Medicaid beneficiaries will transition to the new managed-care system.

In general, mandatory enrollees include most family and children’s Medicaid, pregnant women, non-Medicare aged blind and disabled individuals, and those receiving NC Health Choice.

Groups who will stay in the Medicaid Direct program include those receiving family planning services, those deemed medically needy, those under the health insurance premium payment program, and those in the program of all-inclusive care for the elderly.

Commissioner Brandon Rogers, who serves on the county’s health and human services board, said the main message to folks is to be sure to do something before May 14.

“Don’t wait,” he said. “Go online and make that decision. The biggest thing is to know if your current doctors will be on the plan.”

Commissioner Kirk Kirkpatrick asked Dove whether he knew how many medical providers in the county had signed up with the managed-care companies.

“Basically, they are turning this over to private carriers to save money,” Kirkpatrick said before asking if there was a way to get the information about the Medicaid transformation out to providers who may not be aware of it.

Dove said the department could do that.

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