Introduction
Medicaid is a “health insurance plan for low-income individuals and families who cannot afford health care costs” (Steiner 362). The Medicaid program provides healthcare services to a wide range of demographics. Furthermore, Medicaid is a health insurance plan that covers various medical expenses including hospital bills, doctor bills, dental health, vision-health, nursing home, and mental health costs among others. In the state of North Carolina (NC), healthcare stakeholders are in the process of changing the state’s Medicaid program. According to healthcare stakeholders, the overall goal of Medicaid reforms in NC is to ensure that the program’s budget is predictable and its services are valuable to consumers. In NC, the implementation of the Medicaid program is modeled around the interests of both taxpayers and health providers. This research paper explores Medicaid’s managed care plans in the state of North Carolina.
Types of Medicaid Managed Care Plans in NC
Most of Medicaid’s beneficiaries accrue the benefits of this program by enrolling in managed care plans. Medicaid has several managed-care delivery systems including Managed Care Organizations (MCOs), Primary Care Case Management (PCCM), Prepaid Inpatient Health Plan (PIHP), and Prepaid Ambulatory Health Plan (PAHP). MCOs and PCCM make up the major managed-care plans in NC. The Medicaid government website has listed several of the managed care profiles that are found in NC and they include Carolina Access (CA), Community Care of North Carolina (CCNC), and Program for All-inclusive Care for the Elderly (PACE). CA was established in 1991 with the goal of “taking care of the medical needs of children, people with disabilities, Native Americans, and low-income caretaker adults” (State of North Carolina 1). These four main demographics were included in the original CA program on a mandatory basis. According to the NC’s government resources “older adults, foster care children, dual eligible individuals, pregnant women, and special needs children have the option to enroll” in the initial CA program (State of North Carolina 1). CA was later changed to Community Care of North Carolina (CCNC). NC later incorporated Medicaid into the CCNC/CA in 2008. Current statistics indicate that CCNC/CA healthcare programs account for approximately 80% of all Medicaid enrollees in NC.
Another Medicaid-managed care plan is the “Mental Health Developmental Disabilities and Substance Abuse Services, and it functions under the waiver of Mental Health (MH), Developmental Disability (DD), and Substance Abuse (SA) services” (Norris 1). This managed care plan provides Medicaid beneficiaries with behavioral and healthcare services. Citizens of NC are also offered another managed plan that is known as the Program for All-inclusive Care for the Elderly (PACE). Beneficiaries of Medicaid who are above the age of 55 can be offered any services on the nursing-care level under the PACE plan. The PACE plan accounts for less than 10% of Medicaid enrollees in NC. The Children’s Health Insurance Program (CHIP) is another example of a managed care plan that operates under Medicaid. CHIP offers health-insurance coverage to eligible children through a variety of programs including Medicaid and Medicare. The CHIP program accounts for over 50% of all Medicaid children enrollees in NC.
Enrollment Rates
Currently, NC is one of the over twenty-two states in the United States that are yet to institute an expanded Medicaid system. However, NC has several managed-care plans that are currently operating under the umbrella of Medicaid. The CHIP/Medicaid enrollment statistics are released every month. For instance, in 2014 over eight million children were enrolled in the CHIP/Medicaid program. Nevertheless, statistics indicate that the levels of CHIP/Medicaid enrollment in NC are lower than the ones in the states that have instituted the expanded Medicaid program. For instance, since 2013 most regions in the United States have recorded an increased uptake of Medicaid services. However, the increase in enrollment only applies to the states that have embraced expanded Medicaid. Expanded Medicaid has eliminated most of the barriers that characterized earlier versions of the health care program. The NC Healthcare Department indicated that by May of 2015, the CHIP/Medicaid enrollment stood at approximately two million children. This figure indicates an increase of 22% in average enrollment. On the other hand, the national CHIP/Medicaid enrollment is estimated to be over seventy-one million (State of North Carolina 1). However, these figures represent a 22% increase in Medicaid enrollment within the last year. Therefore, the CHIP/Medicaid penetration rates in NC coincide with those of the national government.
CCNC/CA is the main managed-care program in NC. The beneficiaries of the CCNC/CA program are normally enrolled into the program by the Department of Social Services (DSS). The enrollment categories of the CCNC/CA range from mandatory, optional, and ineligible. The penetration rates of the CCNC/CA programs in NC are mostly hampered by the fact that the state has not passed any legislation to expand the current Medicare system. Currently, 38 states have passed legislation that seeks to expand Medicaid thereby increasing its penetration rate among citizens. Unlike the CHIP/Medicaid plan, CNNC/CA covers a wide range of demographics. Therefore, the penetration rates of CCNC/CA have been hampered by the lack of Medicaid expansion within NC. Statistics indicate that approximately 318,700 people have been locked out of Medicaid due to a lack of expansion formulas in NC. Other sources claim that “there are about half a million people in North Carolina who would qualify for Medicaid if the state expanded the current program to coincide with the stipulations of the federal government” (Norris 1). Nevertheless, there has been a steady increase in the enrollment of the CCNC/CA plan from 2013 to 2015.
Payment Plans for Managed Care Plans in NC
The CHIP/Medicaid plan of NC is modeled around the funding models that are stipulated by the federal authorities. On most occasions “states amend their Medicaid and CHIP plans to effect programmatic and financing changes and to secure legal authority for those changes” (Norris 1). The State of NC uses waivers and demonstrations during the payment processes of managed-healthcare services. All the main waivers and demonstrations are stipulated in “section 1115 demonstrations, section 1915(b) managed care waivers, and section 1915(c) home and community-based services waivers” (State of North Carolina 1). Managed care services are the main tools for delivering payment services to Primary Care Providers (PCPs). Consequently, providers of the CHIP/Medicaid plan in NC are paid every month. NC encourages physicians to participate in its Medicaid-related services by harmonizing healthcare fees with those of the Medicare program. No cost-sharing is necessary for the CHIP/Medicaid plan. On the other hand, CCNC/CA’s payment plan operates similarly with that of the CHIP/Medicaid program except for its dual beneficiaries. PCPs, receive payments for Medicare-Medicaid-related services either in the form of a ‘co-payment’ or a single-payment option.
References
Norris, Lewis. “North Carolina Medicaid.”Health Insurance Organization, 2015. Web.
State of North Carolina. “Medicaid”. Medicaid.gov, 2015. Web.
Steiner, Beat. “Community care of North Carolina: improving care through community health networks.” The Annals of Family Medicine 6.4 (2008): 361-367. Print.