By Liora Engel-Smith
North Carolina’s Medicaid program is shifting roughly two-thirds of its enrollees into managed care this summer, starting on July 1. In the process, thousands of enrollees — some of whom have never had to choose health insurance or a network — were thrust into a process that many have found difficult and confusing.
The state has asked some 1.5 million enrollees to select from five commercial plans managed by private insurance companies (a sixth plan will be run by the Eastern Band of the Cherokee for tribal members) by May 14. With that deadline drawing near, we’ve rounded up some answers to commonly asked questions.
Why is it happening? What does it mean?
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. The move will change Medicaid, the largest public insurer in the state, into something that looks and acts more like private health insurance.
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.
North Carolina is the largest state in the country that hasn’t yet moved to what’s called “managed care.” Nationwide, more than two-thirds of all Medicaid beneficiaries receive most or all of their care via managed care organizations (MCOs). Part of the appeal for state lawmakers is that these companies are mandated to deliver quality care but they’re also “at risk,” meaning that they’re on the hook if costs spiral out of control.
On the other hand, Medicaid is a profitable business for these insurers. Managed care giant Centene, one of the companies that will be providing care in North Carolina, earned $111 billion in revenue and $5 billion in profits in 2020, up from the previous year.
Is this Medicaid expansion?
No. The move to managed care will not change the number of enrollees in North Carolina’s Medicaid program. Instead, it’ll section existing enrollees into narrower insurance networks.
Medicaid expansion is a separate policy debate about adding enrollees to the program under an Obama-era provision of the Affordable Care Act. North Carolina has yet to expand its Medicaid program, and debates over the issue brought the state budget process grinding to a halt in 2019.
Didn’t we do this already?
No, but we came close.
Legislators have been discussing the move to managed care since 2015 with a rollout by 2019. But disagreements over Medicaid expansion that year between Democratic Gov. Roy Cooper and the Republican-led legislature held up the funding for the transition, forcing the Department of Health and Human Services to suspend work on making the changeover.
Who is affected?
Roughly two-thirds of North Carolina’s Medicaid enrollees are affected. These include most families with children, children receiving NC Choice, pregnant women, disabled and blind people who don’t receive Medicare. People with severe mental and physical disabilities will stay with traditional, state-managed Medicaid for now. People in those groups are expected to transition at a later date.
How do I choose a plan?
You can sign up on the web, via an app, over the phone and via mail or fax. To sign up over the phone, call 1-833-870-5500 (TTY: 1-833-870-5588). The line is open from 7 a.m. to 8 p.m. every day, including weekends.
How do I find out which plan has my doctors?
To find out which of the five networks include your current providers, visit the state’s database. You can also call your doctor’s office and ask them directly.
Be aware that, in some instances, this is changing. Doctors’ practices are still signing up with the different MCOs, and your favorite physicians might be willing to sign up with one of the MCOs that meet your needs if you ask them.
What if I missed the deadline or chose the wrong plan?
State health officials anticipate that roughly 15-20 percent of affected enrollees will choose a plan, that’s been the experience in other states that have transitioned to managed care.
The rest of the state’s Medicaid beneficiaries will be enrolled automatically. Everyone — including those who chose a plan — can switch to a different plan in the first year if the one you’re in doesn’t suit your needs.
What if no plan works for me?
Providers have been slow to sign up for the five plans, especially when open enrollment began in early spring amidst the pandemic. North Carolina Medicaid head Dave Richard said that he anticipated more providers will sign up in the coming weeks and most beneficiaries should be able to find an adequate plan.
Richard stressed that each plan is required to provide for its enrollees, even if it means sending patients to doctors who aren’t in network to meet medical needs.
Enrollees who continue to struggle with network issues after the July 1 rollout should contact the state for assistance.
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