Who is eligible
The aged, blind, and disabled. Also, parents with dependent children are eligible for Medicaid with a household income up to 45 percent of poverty level, and children are eligible for Medicaid or CHIP with incomes up to 211% of poverty; maternity-related coverage is available for pregnant women with incomes up to 196% of poverty.
- healthinsurance.org contributor
- September 26, 2016
Will NC expand Medicaid?
North Carolina has not expanded Medicaid under the ACA. And although Governor Pat McCrory said in October 2014 that he was “trying to figure out what to do with Medicaid and whether to expand that or not,” his position appeared to be much more opposed to expansion — for the time being — by late 2015.
Continuing to resist Medicaid expansion could ultimately cost North Carolina $51 billion. McCrory has said in the past that he’s open to the idea of Medicaid expansion, but only after they “fix the current system.” This is a reference to the legislature’s Medicaid reform efforts, discussed below in more detail.
Governor McCrory is up for reelection in November 2016, and his opponent, North Carolina Attorney General Roy Cooper, a Democrat, supports Medicaid expansion. Cooper has said that he’s “appalled by North Carolina’s failure to expand Medicaid to its neediest residents, especially when our tax dollars are already going to pay for it in other states.” The governor’s race in North Carolina is one of the tightest in the country in 2016.
In early 2015, McCrory met with President Obama to discuss a possible Medicaid expansion waiver, and McCrory reported that the President was “… open to certain waivers that I’m looking at to present to my legislature.” McCrory has made it clear that he would want some sort of work requirement tied to Medicaid eligibility for able-bodied adults, but a similar provision was ultimately removed from the waiver proposal in Pennsylvania, and so far, no states have successfully petitioned the federal government to allow a work requirement and still receive federal funding for Medicaid expansion.
Also in January 2015, Brad Wilson, President and CEO of Blue Cross Blue Shield of North Carolina, threw his weight behind the push for Medicaid expansion, noting that “expanding Medicaid is the right thing to do for North Carolinians.”
Thom Tillis, who was sworn-in as US Senator for North Carolina on January 3, used to be strongly opposed to Medicaid expansion. But in October 2014, just two weeks before the previous election, he noted that “we’re trending in a direction where we should consider potential expansion… I would encourage the state legislature and the governor to consider it.” (Tillis defeated incumbent Democrat Kay Hagan in the 2014 election; Hagan supported Medicaid expansion).
Supporters growing impatient
But by late July 2015, McCrory still had not revealed his proposal for Medicaid expansion, and advocates had begun to tire of waiting, pushing the Governor to reveal his plan or admit that he didn’t have one. And State Rep. Ken Goodman (D, Richmond) — a Medicaid expansion supporter — questioned whether McCrory would have the political clout to expand coverage anyway, given that the majority of the state legislature is opposed to Medicaid expansion.
In September 2015, the NC Justice Center introduced radio and digital advertising calling on Gov. McCrory to reveal his plan for Medicaid expansion, noting that he said the holdup was the unknowns surrounding King v. Burwell earlier in the year (the outcome of that case was decided in June 2015, with the Supreme Court ruling that ACA subsidies were legal in every state, and paving the way for states to utilize private health plans for their Medicaid-eligible population).
By late 2015, however, McCrory had mostly walked back his support for Medicaid expansion, explaining that any expansion proposal would have to wait at least three years, while other Medicaid reforms are made in the state (see details below). McCrory and President Obama have “irreconcilable differences” regarding expansion, and McCrory has basically tabled the idea for the time being.
Likely voters in North Carolina favor Medicaid expansion by a 57 to 28 margin.
The impact of refusing Medicaid expansion
North Carolina was one of the last states to adopt the Medicaid program in the first place; only two states took longer to implement original Medicaid coverage. The first states to provide Medicaid did so in January 1966, and North Carolina’s program didn’t become effective until January 1970.
The ACA called for Medicaid expansion in every state, covering all legally-present residents with incomes up to 133 percent of poverty (138 percent with the built-in five percent income disregard). The federal government will pay the full cost of expansion through 2016, after which the states will start to pick up a small fraction of the cost. The states’ portion will never exceed ten percent though.
By not expanding Medicaid, North Carolina is missing out on $39.6 billion in federal funding over the next decade. Instead, the state is subsidizing the cost of expanding Medicaid in other states, since federal tax dollars come from residents of every state, but are being distributed to states that are expanding Medicaid.
Because Medicaid was expected to be available for all low-income residents nationwide, the subsidies to purchase private plans in the exchange were not designed to apply to people living below the poverty level. But in 2012, the Supreme Court ruled that states could not be penalized if they didn’t expand Medicaid, and North Carolina has so far chosen that path.
As a result, there are 244,000 people in North Carolina who are in the coverage gap. Their incomes are under the poverty level, but they are not eligible for Medicaid or for subsidies to help them purchase private health insurance through the exchange. Including the people with incomes between 100 percent and 138 percent of poverty level (who are currently eligible for subsidies in the exchange), there are about half a million people in North Carolina who would qualify for Medicaid if the state expanded the program under the ACA’s guidelines.
North Carolina Medicaid reform
On September 22, 2015, North Carolina lawmakers passed House Bill 372, known as the Medicaid Transformation and Reorganization Act, to privatize the state’s Medicaid system; Governor Pat McCrory signed it into law the next day.
The bill was contentious, and votes were divided mostly along party lines, with most Republicans supporting the measure and most Democrats opposing it. Opposition to the legislation primarily revolved around the introduction of private, for-profit health insurance carriers to the NC Medicaid system. Opponents predicted that change would result in higher administrative costs and could incentivize carriers to withhold care from Medicaid patients in order to curtail costs. They also decried the bill for its focus on privatization of the existing system, without an effort to expand Medicaid under the ACA (North Carolina is one of 19 states that has not yet accepted federal funds to expand Medicaid).
Roy Cooper, the state’s Attorney General and Democratic candidate for governor, has said that “turning to MCOs is a risky move.”
Medicaid managed care by 2019
H 372 calls for the privatization of Medicaid in North Carolina, eventually switching to a model that involves the state contracting with three managed care companies. Those for-profit companies will provide Medicaid managed care plans that will compete with each other across the state. The legislation also calls for the creation of up to ten locally-operated networks of doctors and hospitals (“provider-led entities” or PLEs) that will offer plans across the six newly-created regions of the state. Medicaid benefits will be the same state-wide, regardless of whether the enrollee is in a managed care plan or a PLE plan.
Instead of Medicaid paying providers on a fee-for-service basis, the Medicaid managed care plans and provider-led entities will receive a per-patient payment from the state Medicaid payment, and will be responsible for any cost over-runs beyond what they receive up-front from the Medicaid system. This provision is designed to encourage innovation on the part of carriers and providers, in order to keep patients healthy and reduce overall healthcare costs (as opposed to the traditional fee-for-service model that pays providers each time a service is provided, regardless of overall health outcomes or costs).
Since the federal government funds about two thirds of North Carolina’s Medicaid system, CMS will need to approve the details of H 372 before it can be implemented. The state must send its proposal to CMS by June 2016, and the approval process will likely take at least a year. The Medicaid managed care system would be implemented 18 months after federal approval is obtained, so it could easily be early 2019 before the new system takes effect. Once that happens, North Carolina will join 39 other states that already use managed care systems for some or all of their Medicaid enrollees.
Prior attempts at reform
In May 2014, House Bill 1181 was introduced in the North Carolina legislature in an effort to reform the Medicaid system and move away from a fee-for-service reimbursement system and towards a model that would “reward advances in quality and patients’ health outcomes… and hold providers accountable for meeting budget targets and quality goals.”
The legislation was later revised to call for a shift to a provider-led capitated health plan model that would achieve numerous cost-containment and efficiency goals and would be implemented for the majority of the state’s Medicaid population by July 2020 (this is similar to what ultimately passed in September 2015). A slightly tweaked third version of the bill passed the House with unanimous support on July 2, 2014. Governor McCrory praised the House for their passage of the bill and urged the Senate to pass it as well. But the House and Senate did not agree on the specifics of the Medicaid reform bill though, and the Senate’s version included more radical changes to Medicaid. The Senate passed their version in July 2014, but the House unanimously rejected the Senate’s bill.
The North Carolina legislature reconvened on January 14, 2015, and in March, legislation (H 330) was once again introduced to expand Medicaid. But ultimately, the bill never made it out of committee. In addition to H 372 (discussed above), a variety of other bills, including S 574, S 696, H 525, S 703, were also introduced during the 2015 session to “modernize” Medicaid by switching the existing fee-for-service program to a managed care model. These bills were abandoned in favor of H 372.
Who is eligible now?
The state’s Medicaid eligibility guidelines have not changed since 2013. In addition to the aged, blind, and disabled, Medicaid is available to the following legally-present residents:
- Maternity-related coverage for pregnant women with household incomes up to 196 percent of poverty.
- Children with household incomes up to 211 percent of poverty are eligible for Medicaid or CHIP. In addition, North Carolina provides coverage for some 19 and 20 year olds with income up to 46 percent of poverty level.
- Parents with dependent children are eligible for Medicaid with a household income up to 45 percent of poverty level (for a family of three, income cannot exceed $667 per month).
- The Medicaid-run family planning program, Be Smart, is available to residents with incomes up to 195 percent of poverty. Be Smart provides free family planning and birth control. It was initially set up as a waiver (demonstration) from CMS, but was granted permanent status on October 1, 2014.
Childless non-disabled adults are not eligible for Medicaid regardless of how low their income is.
How do I apply?
- You can apply online at ePass, a website run by the North Carolina Department of Health and Human Services.
- You can also apply in person at the County Department of Social Services office in your home county. DHHS provides a list of documents that you’ll need to take with you if you go to a county office to apply for Medicaid.
- You can print the paper application, complete it, and then mail it to your county’s Department of Social Services office.
- You can apply online through HealthCare.gov or call them at 1-800-318-2596 to apply over the phone.
Medicaid enrollment is available year-round.
How many people are enrolled?
Despite the fact that North Carolina has not yet expanded Medicaid, total enrollment in the program grew by 393,092 people from the fall of 2013 through June 2016 – an increase of 25 percent. These are people who were eligible under the existing guidelines but were not aware of that fact, or had not enrolled for some other reason. The publicity surrounding the ACA and the community advocacy groups that have been helping to enroll people have had a significant impact on getting Medicaid-eligible people enrolled. As of June 2016, the state’s total Medicaid enrollment stood at 1,989,044 people.