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Almost 1.5 million moved to NC Medicaidís managed care. Now what?
As July 1 start looms, there are questions
 
Published Sunday, June 6, 2021 10:30 pm
by Liora Engel-Smith | North Carolina Health News

STOCK PHOTO
North Carolina is moving to Medicaid managed care starting July 1, with 1.5 million residents enrolled in the program.

Fallin McCoy’s new Medicaid insurance card came in the mail earlier this week.

Marked with a red and white logo from WellCare — a private insurer — the connection to the state’s largest public insurer is almost easy to miss.


The old card, a paper document with the North Carolina state seal, lists the state Department of Health and Human Services on top. McCoy’s new card relegated a mention of Medicaid to a small inscription under the massive insurer’s logo.


The plastic is an improvement from the paper, the 39-year-old Carteret County resident said, but it remains to be seen if the improvement would extend to McCoy’s quality of care.


Next month, two-thirds of the safety net program’s enrollees — currently some 2.5 million people — will get their care from 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 first phase of that transition process, the open enrollment period, ended last month.


By all accounts, the transition was a major undertaking. By the end of May, a little over 200,000 enrollees had selected their own plan, while the remaining 1.4 million got assigned to a program automatically, the state health department said in an email. The department’s enrollment hotline fielded more than 280,000 phone calls from enrollees. Roughly 55,000 enrollees signed up on the Medicaid website.

That percentage of self-enrolled versus auto-enrolled is about on par with what’s played out in other states as they transitioned their Medicaid programs to managed care.
State health department spokeswoman Cait Armstrong said in an email this week the effort was “generally successful.” The transition comes after more than five years of efforts by legislators and health officials to reconfigure Medicaid, the largest public insurer in the state, into something that looks and acts more like private health insurance.

Open enrollment hasn’t been seamless for McCoy, whose epilepsy and other health conditions require care from several specialists. Some providers signed contracts with WellCare, and some with rival UnitedHealthcare. WellCare was the better of two imperfect choices, but McCoy still lost a crucial provider. The nearest replacement in her network is in Raleigh, a roughly three-hour drive one way.


With the selection process over, WellCare is responsible for all aspects of McCoy’s care. The state health department will pay the company a flat fee of $1,158 a month regardless of how many tests or prescriptions McCoy needs. It’ll be up to WellCare to pay for services that will enhance and improve her health without losing money.

Managed care companies such as WellCare have done well in the Medicaid market. For example, WellCare earned 8 percent profit on Medicaid revenues of almost $4.9 billion in the third quarter of 2019.


Tying payments to health outcomes should make the state’s Medicaid spending relatively flat and promote better care, proponents say. But exactly how that balance will play out remains to be seen. WellCare did not respond to email and phone inquiries this week regarding this story.


McCoy, for her part, is gearing up for hurdles to come. She wonders if the smaller WellCare network would mean longer wait times for appointments, referrals and other services.


“So far, my providers seem confused and stressed out,” McCoy wrote in a text message this week. “My [primary care provider] seems excited … My specialists seem anxious and concerned.”


Built-in protections
During an interview with NC Health News last month, Medicaid director Dave Richard acknowledged that the transition to managed care may be bumpy at first. State health officials are allowing beneficiaries to continue seeing their existing providers — even if they are out of network — for a few weeks after the plans go into effect.

Insurers will also honor existing preauthorizations. And the state designated the NC Medicaid Ombudsman, an independent nonprofit to educate and advocate with enrollees should problems arise.


These safeguards may not cover every situation, however, said Doug Sea, senior attorney and program manager at the Charlotte Center for Legal Advocacy. Enrollees with significant mental health needs are particularly vulnerable, he added.


The state plans on transitioning these enrollees to managed care plans at a later date, but some beneficiaries who didn’t need to select a plan yet accidentally signed up in the rollout last month. If they don’t switch back to state-managed Medicaid before the deadline, these enrollees will lose some crucial benefits such as rides to and from appointments from the Department of Social Services or placement at drug and alcohol rehabilitation programs.


Sea said the enrollment brokers have reached out to enrollees to discuss these options but worries that the state hasn’t reached everyone in that group.


Some enrollees, Sea said, moved and haven’t updated their addresses with the state and haven’t received information about the upcoming change or their insurance card. And even enrollees who received their cards — particularly those who didn’t pick a plan — may think they no longer have Medicaid.


With providers, enrollees and sometimes even enrollment brokers sharing misinformation on a complicated change, Sea worries that some people won’t know how to navigate their new insurance.


“DHHS is really trying to get the word out,” Sea said. “But it’s an inherently complex system and North Carolina has one of the most complex versions of this in the country.”


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