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!!