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By Liora Engel-Smith
Come July 1, North Carolina’s Medicaid program is being placed into the hands of commercial insurers, and this time, state officials say, the transition is all but guaranteed.
The move will change Medicaid, the largest public insurer in the state, into something that looks and acts more like private health insurance.
North Carolina has been managing the care of its Medicaid beneficiaries since the state-federal program began in the 1960s. Starting in June, roughly two-thirds of the state’s Medicaid enrollees — currently some 2.5 million people — will be divided into one of five commercial plans managed by private insurance companies (a sixth plan will be run by the Eastern Band of the Cherokee for tribal members).
The remaining beneficiaries will transition to the commercial plans at a later date.
At a five-year average of $14.83 billion in combined state and federal spending, Medicaid is one of the state’s biggest budget items. Legislators pushed for making the transition back in 2015, arguing that it would give the state more budget predictability while keeping enrollees healthy. The idea is to pay insurers based on health outcomes, such as controlling a patient’s cholesterol or blood sugar rather than paying for each test, prescription or doctor’s visit.
It’s a big change in the way Medicaid works, particularly for enrollees, some of whom have never had to choose an insurance company or provider network. The process was supposed to take place in 2019, but a budget impasse that year between Democratic Gov. Roy Cooper and the Republican-lead legislature tangled up funding for the transition, forcing the Department of Health and Human Services to suspend work on making the changeover.
As happened in 2019, the state — and the insurers themselves — are reaching out to beneficiaries with digital, television and radio ads as well as mailings about the change.
But that may not be enough in a year where coronavirus response has drowned nearly all other messages.
“I’m a little worried that it might not be on everyone’s radar in the level that it was before the pandemic,” said Jennifer Greene, public health director at AppHealthCare, a health department and community health clinic that serves Alleghany, Ashe and Watauga counties. “[Back then] we were talking a lot about it. We were educating patients, and I think we’re gonna have to work pretty hard to return to that status.”
Dave Richard, who oversees the state’s Medicaid program, acknowledged the transition may confuse some beneficiaries. The state health department estimates that roughly 15-20 percent of enrollees in that first batch will choose a plan, while the rest will be enrolled automatically. It’s a trend that’s played out in other states that have converted to managed care.
Everyone — including those who chose a plan — can switch to a different plan in that first year, Richard said.
Open enrollment started on March 15 and ends on May 14. Despite rolling out for weeks, some beneficiaries say they are already confused and anxious about the transition.
Jereen Wells, a hairstylist in rural Wayne County, did not recall getting any letters from Medicaid about the transition. The 34-year-old did not know about open enrollment and confused the upcoming move to managed care with Medicaid expansion, the separate policy debate that brought the state budget process to a standstill in 2019.
The state health department’s previous attempt to transition only added to her confusion
“I haven’t got anything from Medicaid,” she said. “I remember getting something months ago, but you know, they stopped everything. I’ve heard they started sending out, you know, things again, but I hadn’t got anything this time around.”
Wells, who is generally healthy, was recently diagnosed with a polycystic ovarian syndrome, a hormonal imbalance that can cause unusually heavy periods and puts her at risk for diabetes and heart disease. Medicaid transformation isn’t at the top of her mind, she said, especially in a pandemic year that required the single mom to homeschool her children while also caring for her grandparents.
Losing trusted providers
The process of choosing the right path may not be as straightforward for everyone.
Fallin McCoy of rural Carteret County will likely have to lose at least one of her specialists when she settles on a plan. The 39-year-old, who receives Social Security Disability payments because of a seizure disorder, sees a neurologist, gynecologist, cardiologist and a slew of other specialists regularly. All of her doctors have signed up for one or two plans, but as of this week, there isn’t one plan that includes all of them, she said.
Of the five available plans, she said, only United and Wellcare include some of her specialists, but she’d either have to lose her gynecologist or neurologist in the process.
For McCoy, who is having gynecological surgery later this year, either choice is a blow.
“I’m probably going to have to go with whatever my neurologist takes,” she said.
The difficulties of finding a specialist who takes Medicaid already has McCoy traveling to New Bern or Wilmington to see most of her providers, a trip that usually takes an hour or two each way. With an even narrower provider network to choose from, McCoy worries she’d have to drive three hours or more to Raleigh to see a specialist.
Medicaid head Richard acknowledged that the move to managed care will likely cause frustrating changes for some consumers. He said, however, that each insurer is required to meet their patients’ needs, even if it means referring some patients to an out-of-network provider at the insurers’ expense.
Some of these issues, however, may resolve before the transition as individual providers and health systems continue to join the plans, a process that he said has slowed down because of the pandemic. In order to build their provider networks, the managed care companies need to contract with each hospital, practice group and physician office to get them into their network. The process is time-consuming and continuous.
“We’re not even halfway through open enrollment right now,” he added. “If [consumers] come back in a week or two to take a look and see [that specialist availability] has changed. … If there are people that are getting into a place where they’re unable to find a plan that meets their needs, I would like to know about it.”
This story has been updated to correct the end date of Medicaid’s open enrollment.