Monthly Archives: December 2012

Upcoming Health Care Taxes Could Cripple Medicaid Recipients

Taxes? On health care? But, wait, I thought Obama was expanding Medicaid and allowing more citizens to be covered by Medicaid….Why would he tax the health care industry, which would cause more health care providers to refuse to accept Medicaid?

He has to. By enacting Obamacare and expanding Medicaid, the costs of the Medicaid expansion is staggering, approximately a $1.76 TRILLION between 2012-2021.

Where will the money come from?

Many places…but some places do not make much sense.

There are more places Obamacare is cutting budgets in order to finance the Medicaid expansion. But a critical look at these 3 places from which money is coming offers deep questions as to the logic of expanding Medicaid while taxing the very services and health care entities needed to service Medicaid recipients.

Sales tax on medical devices used by hospitals and

While a 2.3% tax increase on medical devices may not sound ominous, think of this: This sales tax is excised whether or not the medical company turns a profit or suffers a loss.  The tax will hit every single medical device imaginable, from pacemakers, to X-ray machines, to prosthetics.  It is estimated that this tax could yield approximately $29 billion. The manufacturing companies will NOT pick up this tab. No way! The manufacturing companies will raise the prices on medical devices or terminate workers. With unemployment at its current rate, it is illogical to tax medical device companies, who we know, in return, will terminate workers and increase the cost of health care. It seems to be the repercussions of enacting tax laws that negatively affect our country, but these negative repercussions could be eliminated with more forethought. Merely enacting a law that appears on its face to be content-neutral is not enough. Think! Look ahead at possible consequences.  Some legislators have dubbed this tax law the “Job-Killing Tax.”

$716 Billion Slashed from Medicare

Again, on its face, the Medicare reduction in budget does not seem to affect Medicaid recipients. However, sadly, the slash to Medicare will affect those on Medicare, as well as Medicaid.  See my blog “Medicaid Expansion: BAD For the Poor” for a more detailed explanation. But basically, Obamacare promised to increase the reimbursement rate to physicians who accept Medicaid patients. In fact, Obamacare raised the reimbursement rate up to the Medicare rate. Concurrently, in order to pay for the costs of Medicaid, Obamacare slashed the Medicare reimbursement rate. Hence, another political sham. A classic smoke and mirrors rendition of making people believe the Medicaid rate would increase, but decreasing the measurement to which the Medicaid reimbursement would equal.  Today not enough physicians accept Medicaid.  The reason is simple. Physicians are not in the business of free services. If they do not get paid over their own overhead to provide Medicaid services, the easy answer is to refuse Medicaid patients. This causes Medicaid recipients to have little choice of providers and very few choices of providers in specialties.

Taxing Employer-Sponsored Health Insurance

While this tax is not definitely going into effect in 2013, the talk of this tax going into effect is widespread enough to touch on it.  Approximately 1/2 Americans benefit from employer-sponsored health insurance. Mostly, this encompasses American middle class.  These are people who make enough to not qualify for Medicaid, but benefit greatly by the employer sponsoring the health insurance.  These are not the super wealthy. Yet, this potential new tax would impose a great burden onto middle class America. It is foreseeable that the levy would create such a burden on middle class that many people now benefitting from employer-sponsored private health insurance would no longer be able to pay for the increased costs of health insurance premiums and be forced to turn to Medicaid. This would grow the Medicaid population, causing even more difficulty for Medicaid recipients to find health care professionals accepting Medicaid.

Other Obamacare taxes going into effect in 2013 include:

  • Raising the  floor for the deduction of medical expenses on income taxes from 7.5% to 10%
  • Capping individual contributions to flexible spending amounts from $5000 to $2500.

The above-referenced tax laws will affect the middle class. The middle class, if unable to handle these taxes and changes, will become Medicaid recipients. The growth in Medicaid recipients will cause Medicaid recipients to not be able to find a health care provider. Going back to the sales tax on medical devices, it is possible that physicians will no longer be able to provide Medicaid recipients with needed medical supplies, such as wheelchairs or pacemakers, because of the increased price.

I’ve said it numerous times: The Medicaid system is not equipped to handle the number of recipients that will be thrown at it in the near future. Instead of crippling the system and cause more Americans  to rely on Medicaid, we need to fix the Medicaid system. If a Medicaid recipient cannot find a doctor who will accept Medicaid, what is the point of having Medicaid?

NC Group Home Residents Lose Medicaid Funds: May Lose Homes

NC residents who live in Medicaid-funded group homes suffer mental illnesses or developmental disabilities.  Group homes allow the residents a home-like atmosphere and 24/7 health care and personal care services, such as help with toileting, bathing, and eating.

The federal government informed NC that the state was using the wrong eligibility criteria for Medicaid recipients receiving personal care. Personal care services (PCS) is a paraprofessional service that covers the services of an aide in the recipient’s private residence or group home to assist with the recipient’s personal care needs that are directly linked to a medical condition.

To fix the eligibility problem pointed out by the feds, the General Assembly set up a $39.7 million fund to pay for adult care homes, but group homes were unintentionally excluded. If the legislators did not use the word “only” in the legislation, most likely, group homes would have been covered. But in “only” covering adult care homes, group homes were excluded.

The result of the General Assembly’s oversight is that approximately 1400 people may be homeless starting January 1, 2013.

Despite an outcry from the General Assembly for Purdue to call a special session, Purdue refused. Instead, last week, Purdue announced that she was moving $1 million dollars within the Department of Health and Human Services to pay for group homes through January 2013. This allows the group home residents one extra month before Medicaid funding is gone.

The General Assembly organizes January 9th, but is not scheduled to conduct business until January 30, 2013….the day Medicaid funding will cease for the group homes.


NC Awarded $18 Million in Medicaid Bonus

North Carolina is one of 23 states recognized by the federal government as going above and beyond just the normal mandatory national standard of EPSDT (see below for definition) to improve access to children’s health coverage.  The Centers for Medicare & Medicaid Services (CMS) announced that North Carolina, along with 22 other states, will receive bonuses for improving access to children’s health coverage and successfully enrolling eligible children.  The point of the bonus is to offset the costs for enrolling additional children.  States that implement rules that make it easier for children to receive services are the states that receive the annual bonus.  The bonus began in 2009; this is the 4th year in effect.

All states slacken the medical necessity requirement in prior authorization for children under the Medicaid rules through the Early Periodic, Screening, Diagnosis and Testing (“EPSDT”) Program. Although EPSDT is only a start. EPSDT is a national law and required by all states.  So North Carolina must go beyond EPSDT to receive the bonus from the feds.

EPSDT is the child health component of Medicaid.  All children under 21 years of age reap the benefits of EPSDT.  According to Department of Medical Assistant‘s “EPSDT Policy Instructions Update,” “EPSDT services include any medical or remedial care that is medically necessary to correct or ameliorate a defect, physical or mental illness, or condition [health problem]. This means that EPSDT covers most of the treatments a recipient under 21 years of age needs to stay as healthy as possible, and North Carolina Medicaid must provide for arranging for (directly or through referral to appropriate agencies, organizations, or individuals) corrective treatment the need for which is disclosed by such child health screening services. “Ameliorate” means to improve or maintain the recipient’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. Even if the service will not cure the recipient’s condition, it must be covered if the service is medically necessary to improve or maintain the recipient’s overall health.”

States qualify for Medicaid bonuses based on measurements of how well they simplify enrollment and renewal, and how they ensure eligible children have easier access to coverage under Medicaid and the Children’s Health Insurance Program.  Specifically, to qualify for a performance bonus, states must implement at least five out of eight specific program features aimed at streamlining their enrollment procedures to improve children’s health coverage programs and must increase children’s enrollment in Medicaid above a baseline level for the fiscal year.  On December 19, 2012, the Centers for Medicare & Medicaid Services (“CMS”) awarded nearly $306 million in Performance Bonuses to 23 states.

The eight specific program features include:

  • o 12-month continuous eligibility (Allows full-year enrollment regardless of income or other changes.)
  • Elimination or reduced verification of asset requirements
  • No requirement for an in-person interview
  • Same application and renewal forms for Medicaid and CHIP
  • Automatic/administrative renewal (pre-populated form; electronic verification used to streamline renewal)
  • Presumptive eligibility (allows health care providers and other entities to screen and presumptively enroll children; children have access to needed benefits while the full eligibility process is being completed)
  • Express Lane Eligibility (States can use eligibility findings from other public benefit programs, such as the Supplemental Nutrition Assistance Program (SNAP) to determine eligibility for Medicaid and CHIP.)
  • Premium Assistance-

The amount of a state’s bonus correlates with the increase in Medicaid enrollment: the more children enrolled, the higher the bonus. States that increase enrollment more than 10 percent above their baseline receive a larger (Tier 2) bonus.  North Carolina reached the Tier 2 bonus this year and last year.

This year, Colorado was the big winner with $42.9 million. (I’m not really sure if “won” is the correct word, but I’m sticking with it for the purposes of this blog).  Maryland won $36.4 million. Georgia won $1.9 million.  Wisconsin won $23.3 million. Oklahoma, which won a small $481,452, in 2011, won nada in 2012, 2009, and 2010. New Jersey won $22.2 million.  Of states actually winning any amount of Performance Bonus, Indiana was the big loser with $1.42 million (not bad for the lowest).

In 2009, North Carolina received zero from the Performance Bonus. Again, in 2010, North Carolina received a big goose egg. In 2011, North Carolina received $11,567,319.  Now this year, we received $17.9 million (rounding it to $18 million). Not bad improvement from 2009 and 2010!!! This year, we were the 8th largest winner.  Let’s go, North Carolina!!


Medicaid Budget Increased By Medicaid Fraud

The State of North Carolina and the federal government is on a “Fraud Rampage!”  Those entities engaging in Medicaid fraud: Beware!

North Carolina authorities have arrested 18 health care providers accused of defrauding the state Medicaid system, Attorney General Roy Cooper said Monday.

The charges allege more than $500,000 in fraudulent payments combined. The state is pursing criminal convictions as well as restitution of money from the accused, Cooper said.

These arrests come on the heels of North Carolina receiving $16 million from Abbott Laboratories a couple months ago.  Abbott settled a national Medicaid fraud case, and $16 million was North Carolina’s portion.  Abbott was accused of advertising its anti-seizure drug Depakote for non-FDA approved health conditions, such as dementia and autism.  A doctor may prescribe a drug for off-label purposes, but a manufacturer may not advertise its drugs for off-label purposes.

Whew…that $16 million padded the Medicaid budget, right?  Well, not so fast. Remember Perdue just took $20 million from Medicaid.  Maybe the settlement helped out Perdue’s decision to take $20 million from Medicaid to give to pre-K programs. Who knows? I guess with $20 million out and $16 million in, the Medicaid budget is still lacking.

So, North Carolina will need to find more fraud. Already, we can expect approximately $500,000 from 18 health care providers arrested for Medicaid fraud.


The NC Medicaid System is Broken: FIX IT!!

People covered by Medicaid receive worse medical service than people with private insurance.  This is a fact.  It is a sad fact, but a fact nonetheless.  Hundreds of studies have shown this fact.  Here are a few:

A recent study published in the New England Journal of Medicine examined pediatric access to specialty clinics in Cook County, Illinois.  The study sent out research assistants posing as mothers and making phone calls to a random sample of specialty clinics, the study found a significant disparity between access to specialty care for privately insured children and children on Medicaid as well as the publicly funded Children’s Health Insurance Program (CHIP). Specifically, the researchers noted more denials of appointments as well as longer waiting times for Medicaid and CHIP patients than for privately insured patients.

A very scary study conducted on North Carolina‘s Medicaid in 2010 published in the State Center for Health Statistics, found that the North Carolina Medicaid population experiences a much higher rate of overdose deaths than the North Carolina population. This study suggests that fatal overdose among the Medicaid population are associated with claims for mental health disorders, substance abuse, and routine medical care for pain management.

A 2000 study published in the American Journal of Public Health that examines colorectal cancer treatments and outcomes found that Medicaid patients not only had higher mortality rates, but were also less likely to receive cancer-directed surgery, than patients using commercial fee-for-service insurance.

A 2010 study in the Journal of Hospital Medicine found similar results for non-cancer-related illness. In this study, the authors examine the relationship between insurance status and health outcomes for myocardial infarction, stroke, and pneumonia patients.  The authors statistically analyzed a nationally representative hospital database and noticed, even after adjusting for factors such as age, gender, income, other illnesses, and severity, higher in-hospital mortality rates for Medicaid patients than for privately insured patients. Additionally, even after adjusting for these factors, the study found that Medicaid patients hospitalized for strokes and pneumonia also ran up higher costs than the privately insured, as well as the uninsured.

A 2012 study in Health Affairs examined physicians’ willingness to accept new patients. Using survey data from a nationally representative sample, the study found that nearly one-third of physicians nationwide will not accept new Medicaid patients. Doctors in smaller practices, as well as doctors in metropolitan areas, are among the least inclined to accept new Medicaid patients.

So, with the understanding that  the Medicaid system  is failing those very people it is designed to protect, why are our political leaders ignoring the broken system and merely dumping more people into the failing Medicaid system????

With Obamacare‘s Medicaid expansion, hundreds of thousands of people will be dumped into this broken Medicaid system with zero political effort to FIX the system. In NC alone, if we expand our Medicaid, approximately 720,000 more North Carolinians will be Medicaid eligible.

Obama proponents would, most likely, argue that Obama raised the Medicaid reimbursement amount to physicians to meet the Medicare reimbursement rate. Raising the Medicaid reimbursement rate tempts more physicians to accept Medicaid.

I agree with the last sentence of the above paragraph. Raising the Medicaid reimbursement rate WOULD cause more physicians to accept Medicaid. But that is not what Obamacare does.  Obamacare does not raise the Medicaid rate to all physicians, only primary care physicians, and only temporarily.  And even the raised rate for primary physicians is nominal, at best. Because, during the 2012 election,  while Obama was standing on his platform of higher Medicaid reimbursement to physicians…up to the Medicare rate….Obama was slashing the Medicare reimbursements. It’s the old bait and switch. GOTCHA!

Again I ask: Why are our political leaders ignoring the broken system and merely dumping more people into the failing Medicaid system????

Medicaid expansion will cause more people to be declined medical treatment by providers, cause people to receive sub-par health services, and to the extreme, cause deaths when those deaths should not have happened.

Unintentional overdosed (UO) deaths have become the second leading cause of unintentional injury deaths in the United States, exceeded only by motor vehicle injuries. (1)  North Carolina UO death rates exceed the national average.  The Medicaid population represented approximately 20 percent of the overall state population in 2007, but it experienced one-third of the unintentional overdose deaths.  (2)

Instead of expanding Medicaid to more people,  our leaders need to fix the Medicaid system first. Fixing the Medicaid system should be the number one top priority.  Not exasperating the problem by dumping 720,000 more North Carolinians into the Medicaid system. FIX IT!! 

Make sure that if I hold a Medicaid card that (1) I am able to get an appointment with the proper physician; (2) that the physician I visit does the very best he or she can to ameliorate my problem (as if I were on private insurance); (3) provide me with any needed test to determine the cause of my problem; (4) allow me to have follow up appointments.

In essence, those with Medicaid should receive the same care as those on Blue Cross (not saying Blue Cross in the bee’s knees).



How Medicaid Handles Mental Illness

Mental health in this country is not handled well. That is an understatement!!! Look at the atrocity in Connecticut last week. An young man, supposedly suffering from Asberger’s, a mild type of autism, shot his way into an elementary school and proceeded to slaughter young children and women. Our country does not handle mental health. However, mental health issues exist, are common, and are not treated appropriately. We cannot act like an ostrich and poke our heads in the sand.

The horrifying events of last week’s elementary school slaughter should make us realize that something must be done with how this country handles mental illness.  Folks, it’s not the guns that need control. Gun cannot act on their own. The people holding the guns need to be reasonable and sane. People who suffer mental illness in this country need real services. Real help.

How North Carolina handles mental illness is about to change drastically. The entire Medicaid mental health system is changing. This may be the biggest re-vamping of mental health we have undergone. If it doesn’t work, it will cost billions to change the system back. How will it change? See below.

The sad truth is mental illness is a very under-treated health condition. The stigma that attaches to it is one reason.  But poverty is also a factor.

The N.C. Interagency Council for Coordinating Homeless Programs (ICCHP) conducts an annual survey of homeless people.  In 2008, the statistics were as follows:

  • 12,371 people identified as homeless, including
  • 3,643 people in families, 2,216 of whom were children.
  • 1,054 identified themselves as veterans of military service.
  • 1,961 identified themselves as having a serious mental illness.
  • 4,206 identified themselves as having a substance use disorder.
  • 1,108 identified themselves as being a victim of domestic violence.
  • 6.5 percent of people identified themselves as having been released from the criminal justice system.
  • 6 percent of people identified themselves as having been released from a mental health hospital or drug treatment program.

Half of the homeless identified themselves as suffering from a mental illness or suffering substance abuse! Half! How many homeless suffer a mental illness without a diagnosis?

These are people who should be receiving Medicaid. In order to receive mental health services covered by Medicaid, the mental health services must be determined to be medically necessary to treat the mental illness.

So what is “medical necessity?”

Medicaid covers procedures, products, and services when they are medically necessary. With all the Medicaid rules and regulations, somewhere, medical necessity must be defined. It is not. In North Carolina Clinical Policy 8A, medical necessity is described as: “All Medicaid services are based upon a finding of medical necessity, which is determined by generally accepted North Carolina community practice standards as verified by independent Medicaid consultants. There must be a current diagnosis reflecting the need for treatment.”  What?  Basically, an independent consultant, as of now, VO, must decide whether a health care service is medically necessary. Despite the amorphous definition, medical necessity has been somewhat uniform because all the prior authorizations went through VO. It did not matter in which county you lived. VO was state-wide.

Not for long. In upcoming changes to NC Medicaid, VO will no longer be the independent consultant for North Carolina’s mental health.  The State is creating Managed Care Organizations (“MCOs”).  Suffice it to say, if you are a health care provider in North Carolina, you have heard the term “MCO.” What is an MCO? I guess the correct question is what will be an MCO?

The best way to describe the new Medicaid system in North Carolina, I think, is to explain the process for getting prior approval now and explain how it will change in the upcoming 6-7 months.

To obtain prior authorization now for mental health services, the provider sends documents, usually a Person-Centered Plan (“PCP”) with a Service Order, among other papers, to ValueOptions.  Since 2006, VO has provided North Carolina with utilization management. Meaning health care professionals at VO would review the documents and determine whether the Medicaid recipient met “medical necessity” in order to receive the services requested.

When the MCOs take over, there will be no state-wide definition for medical necessity.  There will be no state contract with VO. Basically, the State will disperse all the Medicaid funds to the MCOs.  No one really knows how many MCOs there will be in North Carolina.  As of now, it appears there will be 12 or so. Alliance Behavioral Health will be one. Wake County could not get qualified on its own, so Wake County partnered up with Durham County.

The thought process was this: The State is too big to understand the needs of local regions. So let the localities decide what services are needed in Medicaid’s mental health. On paper, I think it sounds good. Trying to focus locally is a good thing. The problem I foresee is the lack of a uniform, well-defined criteria for medical necessity in mental health.

It is foreseeable that each different MCO will have different opinions as to what services are medically necessary or not. In Charlotte, Medicaid may cover hyperbolic oxygen treatment for autism. But Raleigh may not. In Raleigh, Medicaid may limit psychiatrist visits for people with violent tendencies, and, in Wilmington, the psych visits may be unlimited. A Medicaid recipient may be denied in Roxsboro for mental health services that would be covered if that Medicaid recipient lived in a different MCOs region.

Mental health is such an important topic. In the wake of the killings in Connecticut, we, as a country, need to learn to better provide services to those with mental illnesses. Medicaid recipients need solid mental health services. With the MCOs provide better mental health services? Maybe. But I think a good start would be to provide a state-wide definition for medical necessity.

Perdue: Takes $20 Million From Medicaid, Gives to Pre-K Programs

In one last hurrah, Perdue took $20 million from DHHS, or the Medicaid budget, and redistributed it to the Pre-K Program, formerly known as More at Four. The Medicaid budget is extremely tight as it is; the budget cannot even cover all the Medicaid services, much less fund another program.

At the end of the last fiscal year, the General Assembly needed to appropriate an additional $212 million to Medicaid to cover a budget shortfall that had grown over the previous year.

NC Secretary of DHHS, Al Delia, stated that the $20 million came from the AIDS Drug Assistance Program, foster-care services, funding reversions and unspent salaries.  Which begs the question, if there were unspent monies in the Medicaid budget, why did DHHS ask the General Assembly a few months ago for $212 million to finish the fiscal year?

Although it is important to note that Perdue was acting via a Court Order. Personally, I’d like to see the Court Order. I’d like to see whether the Order ordered the funds to come from DHHS. Because Medicaid funding is the one of last budgets I would dip into.

Obamacare Medicaid: All or Nothing!!

On Monday, the Feds said, “NO!” to partial participation for states in the federal Medicaid plan. Now the states will need to decide to expand Medicaid per Obamacare (“go all in”) or not (“fold”).

For the past few months, we have heard governor-elect Pat McCrory state that he was interested, as were most Republican governors, in a partial participation in the  federal expansion of Medicaid.  Meaning, the states would expand Medicaid, but not quite as much as Obamacare requires. Well, this is no longer an option.

Monday, Secretary of Health and Human Services Kathleen Sebelius, authored a memo that stated “the law does not provide for a phased-in or partial expansion.”  Sebelius reiterated Obama’s claims that the federal government will handle 100% of the costs of covering new enrollees in 2014, 2015 and 2016, and at least 90% in subsequent years.  However, this claim of the federal government “picking up the tab” has been under intense scrutiny.  First, no one knows where the colossal amount of money will come from, although Obama has slashed the upcoming Medicare budget by over 716 billion. Secondly, states are terrified that, once 2017 comes, the states will not be able to afford the Medicaid bill.

For states that do not decide to accept federal dollars to expand, those states will continue to receive federal funding status quo, at least from 2014 through 2016.  Those states would receive their regular federal match rate — which varies from 50 percent to 78 percent, depending on the state.  After 2016, it appears that the states could apply for federal permission for a partial expansion.
There is no deadline for states to make a decision on expansion, unlike the related decision about whether to operate a state-based insurance exchange. But states that opt-in sooner, will be eligible for increased federal funding.  No doubt the decision  on expansion will rest largely with state legislatures as they try to set the 2014 budget.
As for the decision to run state-based insurance exchanges, that the blueprints are due to the federal government Friday if the state would like to run its own state-based exchange.  As of Monday, the feds have received  formal plans from 14 states and the District of Columbia to set up their own exchanges, and that they had reviewed and approved six of them: from: Colorado, Connecticut, Massachusetts, Maryland, Oregon and Washington state.  The administration will sign off on those plans on a rolling basis.  There is no deadline by which states must declare their intentions regarding the Medicaid expansion.

According to a Forbes blog, just more than a dozen states appear certain to take part in the expansion. In about 13 states, officials have been leaning heavily against it. In the remaining states, the decisions are uncertain.  The Forbes blog has NC as uncertain.  No shock there. McCrory has only stated that he wants to research the possible consequences of expansion before making a decision.  A statement, in my mind, that shows McCrory is inclined to make an educated decision, instead via party lines.  He may also have been waiting to see whether NC could have submitted a partial expansion, but now that is not an option.

The fundamental question NC state leaders have to ask is, “Do I believe that NC will continue to get 90 percent of the cost of the expansion from the federal government perpetually, given that the federal government has no money?”


Will YOU be Medicaid Eligible on January 1, 2013?

Ok, Maybe not exactly on January 1, 2013. But starting January 1, 2013, new rules will be implemented from Obamacare, and, slowly, changes in Medicaid eligibility will occur.  Realistically, in may take a year for NC to adjust.

To qualify currently for the North Carolina Medicaid program, a person must be a citizen or lawful permanent immigrant in the United States for at least five years and must meet certain categorical, income and resource requirements.  The individual must also have an income below a certain income threshold and have limited resources (depending on the size of the family) or assets to qualify.

Imagine, as of now, a person working at minimum wage ($7.25/hour), 40 hours week, and 50 weeks/year and earn $14,500/year, is generally making too much money to be Medicaid eligible.  For example, a parent in a family of four would only qualify in North Carolina if his or her income was less than $7,128/year, equivalent to less than half of what a person earns on minimum wage.

The best way to illustrate who will be covered by Medicaid in the future is a chart:

                                  2011 Income Eligibility/Year              2013+ Income Eligibility/Year

Category                 % Fed Poverty        Medicaid                      % Fed Poverty        Medicaid

Child Age 0-5                   200%                   1:<$21,780               200%                      1:<$21,780

Child Age 5-18                100%                    1:<$10,890                138%                       1:<$15,028

Pregnant Woman           185%                    2:<$27,214                185%                      2:<$27,214

Parent of Dep. < 19         1:40%                    1:<$4,344                138%                    1:<$15,028

Adult, 0 children           Not eligible          Not eligible               138%                    1:<$15,028

After 2013, the income guidelines for an individual (single adult without dependent children) would be $15,028/year or $30,843/year for a family of four if based on 2011 federal poverty levels.

Obviously, this is a huge expansion. Low-income adults is the category impacted the most.

So, after the BIG CHANGE, will YOU be Medicaid eligible?


NC “RAC” Moves to Hospice: More Recoupments to Come

“RAC” is an acronym for Recovery Audit Contractor. PCG is North Carolina’s RAC. What does that mean? It means that PCG will review all past Medicaid payments (from prior years) to determine whether Medicaid overpaid (or underpaid) the health care provider. The reason NC is conducting these post-payment reviews is because the federal government (Obamacare) requires it.

In September 2011, the Centers for Medicare &Medicaid Services (CMS) published the Final Rule for RAC.  Mandated by the Obamacare, the Medicaid RAC Final Rule required states to implement their Medicaid RAC programs by January 1, 2012 or lose federal funding. RACs must follow federal and state guidelines to recover overpayments or to inform DMA of underpayments.

So for the past year, PCG has been auditing Medicaid payments to health care providers.  While the law requires PCG to determine underpayments and overpayments, I would venture to guess that the number of underpayments (where the State owes the provider more money) is less than 1% of the findings.  Maybe 0. Although maybe I don’t hear about the underpayments because, as a Medicaid lawyer, no one contacts a lawyer because the State pays them more money. But, if I were a gambling person, I would put my money on the fact that PCG is finding most, if not all, post payments were overpaid. I’d love to hear from a health care provider who received more money from the State as a result of being underpaid initially.

As of the end of November, PCG hasn’t audited hospice providers. Well, hospice providers, here comes PCG. Starting December 2012, PCG will be auditing hospice providers, specifically looking for providers who billed services concurrently with recipients who were receiving all-inclusive care.