Haven’t Fixed Medicaid Yet…But I Haven’t Gotten Bucked Off Yet

There are a number of federal regulations that, if I were in charge, would be immediately amended. Obviously, I am not in charge, so despite my best blogging efforts, my blogs do not change federal law. Today, however, I had the honor and privilege to speak to someone who may have the clout and political pull to fix some of the calamities found in the Code of Federal Regulations (CFRs) that are so detrimental to health care providers who accept Medicare and Medicaid across the country.

My husband, daughter, and I ride horses nearly every weekend. We ride Western and on trails all over North Carolina and Virginia, mostly on charity rides. And over the past few years, I have, sadly, gone through over 5 horses. Not because the horses have passed. But because each horse had an oddity or behavior issue that either (a) I didn’t want to deal with; or (2) terrified me.

For example, Twist of Luck (Twist) is a gorgeous pure, white horse with a yellow tail and mane and brilliant, blue eyes. But he was what you call, “proud cut.” Meaning that because he sired so many foals, even after he became a gelding he thought like a stallion. One weekend we were at Uwharrie National Park and when I saddled up Twist and mounted him, he decided that he did not want me on his back. My husband said Twist looked like a “poster horse” for a rodeo with his back completely rounded like an angry cat and all four of his hooves in the air. Needless to say, I found myself quite quickly on the ground with a sore tooshie, and Twist found himself sold.

Since I do not have the time to actually train my horse, I need a trained horse.

With my hobby of horseback riding, a well-trained horse is imperative…not only for safety, but for my enjoyment as well.

In the area of Medicare and Medicaid, it is imperative for enough physicians, dentists, and other health care providers to accept Medicare and Medicaid. You see, health care providers choose to accept Medicare and Medicaid. And not all health care providers agree to accept Medicare or Medicaid. But it is important for enough health care providers to accept Medicare and Medicaid patients otherwise the Medicare or Medicaid card in a person’s hand is worthless. Same as Twist was worthless to me that day in Uwharrie. If you can’t ride a horse, what is the point of owning it? If you can’t find a health care provider, what is the use of having coverage?

Here in North Carolina, we decided to not expand Medicaid. This blog is not going to address the ever-growing discontent in the media as to the decision, although you can see my blog: “Medicaid Expansion: Bad for the Poor.”

Instead, this blog will address my idea that I pitched to Congresswoman Renee Ellmers over lunch last week and discussed today with her legislative counsel today as to how it can be implemented.

Here’s my idea:

According to most data, not expanding Medicaid in North Carolina is affecting approximately 1.6 million uninsured North Carolinians. But to my point of the shortage of health care providers accepting Medicaid, what is the point of having an insurance card that no health care provider accepts? Therefore, I propose a pilot program here in NC…a pilot program to help the approximate 1.6 million uninsured in NC. Besides the moral issue that everyone deserves quality health care, fiscally, it is sound to provide the uninsured with quality health care (notice that I did not say to provide the uninsured with Medicaid). When the uninsured go to emergency rooms it costs the taxpayers more than if the uninsured had an insurance policy that would allow primary care and specialty doctor appointments. But with Medicaid…you can count out most specialty care, even some basic necessary care like dental care.

Most of the uninsured in NC are non-disabled men. I say this because it is usually easier to get a child on Medicaid with the Early, Periodic, Screening, Diagnostic, Testing (EPSDT) laws. See my blog: “How EPSDT Allows Medicaid Recipients Under the Age of 21 To Receive More Services Than Covered by the State Plan” for an explanation of EPSDT. Many women receive Medicaid based on having dependent children. “In most states, adults without dependent children are ineligible for Medicaid, regardless of their income, and income limits for parents were very low—often below half the poverty level.” See Kaiser Foundation. Which means, generally, many of our uninsured are men without dependents. However, that does not mean they are not fathers. Many of the uninsured are fathers.

Two-thirds of the uninsured live in families where there is at least one full-time worker. However, the percentage of uninsured who live in families with no workers, part-time workers and only one full-time worker has increased 12 percentage points over 5 years. See Demographics.

So how do we help the uninsured without merely handing all uninsured a Medicaid card that will not give them quality health care because not enough trained health care providers accept Medicaid patients?

By giving the uninsured health care insurance, of course! But not Medicaid coverage…oh, no! By giving the uninsured private insurance that will be accepted by all health care providers, all specialists, all durable medical equipment companies, all dentists…

We could partner up with a larger insurer like Blue Cross Blue Shield (BCBS) and create a premium health care insurance on which the insured would pay no premiums or co-pays. Instead, federal grant money would cover the premiums. All that money that NC did not receive based on our decision to not expand Medicaid…can go toward this pilot program to purchase the private insurance for the uninsured.

In order to qualify for this premium, free, private insurance the person must:

1. Be a legal resident;
2. NOT qualify for Medicaid; and
3. Maintain a part time job.

The reasoning behind the criterion of maintaining a part-time job is simple.

It is indisputable that the Affordable Care Act (ACA) has motivated employers across America to decrease the number of full-time jobs due to the mandatory expense of employers providing health care to full-time employees.

Obviously, part-time work does not pay well. It is difficult to even maintain a living on part-time work’s low hourly wages. Many people are forced to hold down two-part time jobs in order to survive. If you can not work and receive more government hand outs, what is the incentive to work?

If my idea comes to fruition and many of our uninsured carry a private insurance card and receive quality health care from the providers of their choice, we could create a whole new group of North Carolinians not only contributing to the community by working, but also contributing to their own homes, and improving themselves and those around them.

I don’t want to provide anyone a useless piece of paper that does not provide quality health care. We may as well give everyone a “proud cut” horse that no one could ride.

Thank you, Congresswoman Renee Ellmers, for being willing to listen to me regarding the uninsured and actually follow-up with the intent to implement.

Quality health care is imperative. Necessary. Needed. We need to fix this system.

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on September 5, 2014, in Accountability, Affordable Care Act, Division of Medical Assistance, Doctors, Eligibilty, EPSDT, Federal Government, Federal Law, Health Care Providers and Services, Legislation, Medicaid, Medicaid Attorney, Medicaid Costs, Medicaid Eligibility, Medicaid Expansion, Medicaid Recipients, Medicaid Reform, Medicaid Services, Medicaid Spending, Medicare, Medicare Attorney, NC, NC DHHS, North Carolina, Number of Medicaid Enrollees, Obamacare, Tax Dollars, Taxes, Taxpayers, Uninsured and tagged , , , , , , , , , , , , , , , , , , , . Bookmark the permalink. 9 Comments.

  1. This isn’t new stuff. When I was in Maryland 20 years ago, Medicaid contracted with BC/BS so that Medicaid patients became BC/BS patients. We had a large capitated population through the BC/BS HMO for which we received a certain number of dollars per member per month based on age and gender. The Medicaid patients were part of that mix. Patients paid co-pays when they came to see us. North Carolina remains behind the times. Partisan politics has taken priority over rational decision making in this area in my opinion.

  2. I second that motion!!

  3. Nice. Very nice. Linda

    Sent from my iPhone


  4. You’re talking about a grant for a pilot program. OK, but where does the REAL money come from to roll it out? Remember the root of all our problems is a lack of money…whether it’s to expand Medicaid coverage or other programs.

  5. It was working well at the time I was there which extended until 1997. We had two big HMO organizations MD IPA and Delmarva Health Care Plan with a total of 5000 or so capitated patients on our panel lists. Medicaid patients were included on the panel when DHP was bought by BC BS. We did referrals, etc just as we did for other HMO patients. I don’t know what happened after 1997 since I moved to NC then.

  6. Providers Not Enrolled in Medicaid (August DMA bulletin) 42 CFR 455.410 requires that all ordering, rendering and referring physicians – as well as other professionals providing services under the N.C. Medicaid, N.C. Health Choice (NCHC) or their respective waiver programs – be enrolled as participating providers. This includes anyone who orders or refers Medicaid and NCHC beneficiaries for items (such as pharmaceuticals) or services and seeks reimbursement. The National Provider Identifier (NPI) of the ordering or referring health care professional must be included in all claims for payment. Enrollment criteria are being developed for providers with taxonomy codes that aren’t currently being processed by NCTracks. The information will be posted on the DMA Website and an announcement will be made via NCTracks. June 2014 Pharmacy Bulletin On January 1st, 2013, pharmacy providers began to receive a message at point-of-sale for prescriptions written by prescribers not enrolled in the Medicaid program. The edit, 00951 states “M/I PRESCR ID – NO ID ON FILE” with EOB 02951 message “PRESCRIBER NPI NOT ON FILE. CONTACT PRESCRIBER AND REFILE WITH CORRECT NPI”- Currently claims pay on this edit, but claims will deny starting on November 1, 2014. This will hold true for originals and refills. If you see this edit, please inform your patients that on November 1, 2014 their prescriptions will no longer be covered by Medicaid because their physician is not a Medicaid provider. Kathy Nichols, LCSW N.C. Department of Health and Human Services Behavioral Health Section, DMA Katherine.Nichols@dhhs.nc.gov http://www.ncdhhs.gov/dma

    Sent from my iPad


  7. The fact that consequences might be unintended does not necessarily mean that they were not, or could not have been, anticipated.

    For example, it might well have been anticipated that offering highly educated and trained professionals sixty cents on the dollar, eventually, plus a ton of grief in exchange for their services would cause many of them to withhold their services in favor of other opportunities.

    I have little difficulty understanding why states, which know that the fe(de)ral government is funding its share of Medicaid with borrowed money, would be reluctant to expand Medicaid eligibility based on additional fe(de)ral government funding with additional borrowed money; and, the anticipation that the fe(de)ral government share of funding would decline over time, shifting the funding burden to the states.

    As has been the case with both Medicare and Medicaid:
    1 – there is no such thing as a “free lunch”;
    2 – the better lunch is, the more it costs; and,
    3 – once you start eating, you can’t stop.
    I am confident that, with the passage of time, we will discover that the same is true for PPACA; and, that we will come to realize that this result could have been anticipated as well.

    Don’t begin vast programs with half-vast ideas. (healthcare.gov, NCTracks, etc.)

  8. The numbers Knicole previously gave in her blog show the cost to provide a private health insurance ‘Cadillac’ plan as being lower than the cost of providing and administering Medicaid in NC. I’m thinking this is a fantastic idea that should definitely be explored.

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