Category Archives: Carolina ACCESS

Carolina Access, Medicaid and Health Choice: What Are These Programs and Who Qualifies?

Medicaid, Carolina Access, and Health Choice.  Three completely different, and, somewhat, independent programs.  What are the differences?  Who is eligible for what? 

I am reminded of the Monty Hall problem that I learned in a college Statistics class (which, BTW, was my most-hated class in college).  The Monty Hall problem is a brainteaser, a hypothetical, statistical mindbender and it goes like this:

Suppose you’re on a game show, and you’re given the choice of three doors: Behind one door is a car; behind the others, goats. You pick a door, say No. 1, and the host, who knows what’s behind the doors, opens another door, say No. 3, which has a goat. He then says to you, “Do you want to pick door No. 2?” Is it to your advantage to switch your choice?

I am not alluding that Medicaid, Carolina Access, and Health Choice are the equivalent of picking a prize from behind three doors.  Obviously, not.  But when you don’t know the difference between the programs or which program could benefit you, it can seem as if you are just picking a prize behind three doors.  Or throwing darts at a dartboard of choices.  Without information, knowing which program can benefit you can be a mystery. 

In this blog, I would like to take the mystique out of Medicaid, Carolina Access and Health Choice.  So that you know which program, if any, could be applicable to you, a relative, friend, or, even, a client.

First, door number 1: Medicaid is health insurance for low-income families and individuals who are eligible.  Depending on the category for which you are applying, the income cap differs.  For a complete rundown of Medicaid eligibility, click here.

Medicaid is a highly regulated program, both federally and on the state level.  But no federal statutes speak to how Medicaid recipients can choose their health care physicians or a long-term treatment plan.

Hence, door number 2:

Carolina Access (CA).  CA is an option for comprehensive managed care that directs Medicaid recipients to primary-care doctors or clinics that can best serve all their needs. CA helps find Medicaid recipients “health care homes.”  With CA, recipients also have 24-hour access to medical advice and emergency treatment. 

If you are eligible for Medicaid, you may be eligible for CA, but not always.

CA began as a pilot program within 5 counties in 1991 and went statewide in 1998.

Medicaid recipients are enrolled in CCNC/CA by the Department of Social Services located in the county in which they reside. Enrollment can be done at anytime during the recipient’s eligibility period; however, it is required at application or review for continuation of eligibility. The program aid category of eligibility determines if a recipient is mandatory, optional, or ineligible for enrollment in CCNC.  See NC DMA website.

Below is a chart of eligibility for CA:

MANDATORY OPTIONAL INELIGIBLE
AAF (Work First Family Assistance) HSF (Medicaid Non-Title  IVE Foster Care Children) MQB (Medicare Qualified Beneficiaries)
MAB (Aid to the Blind) IAS (Medicaid Title IVE Adoption Subsidy Foster Care Children) MRF (Medicaid for Refugees)
MAD (Aid to the Disabled) MPW (Medicaid for Pregnant Women) RRF (Refugee Assistance
MAF (Medicaid for Families and Children) MAA (Medicaid for the Aged – over 65 years of age) SAA (Special Assistance to the Aged)
MIC (Medicaid for Infants and Children)    
MSB (Special Assistance to the Blind)    
SAD (Special Assistance to the Disabled)

According to the December 2013 CCNC/CA Enrollment Report, there were 1.58+ Medicaid enrollees throughout North Carolina.  1.47+ of those Medicaid enrollees were eligible for CA.  1.35+ actually enrolled in CA at a 92% realization rate.

And now we come to Door #3:

Because Medicaid only covers those with low-incomes and many people who are not eligible for Medicaid still cannot afford insurance, NC has created door number three: Health Choice.  Health Choice only covers children.  Eligibility for Health Choice is defined by NC statute.  According to NC Gen. Stat. 108A-70.21, children are eligible for Health Choice if they are:

  • Between the ages of 6 through 18;
  • Ineligible for Medicaid, Medicare, or other federal government-sponsored health insurance;
  • Uninsured;
  • Live in a family whose family income is above one hundred thirty-three percent (133%) through two hundred percent (200%) of the federal poverty level;
  • A resident of this State and eligible under federal law; and
  • Someone who has paid the Program enrollment fee required under this Part.

So….there it is….the three programs, Medicaid, Health Choice and Carolina Access, somewhat de-mystified. 

I understand that I cannot cover all aspects of all three programs in this blog, but, hopefully, this helps a bit.  So it does not feel like you are picking randomly a prize from 3 doors.

Tip #6: Avoiding Medicaid Recoupments

This tip, Tip #6, is devoted to Outpatient Behavioral Health providers.

Outpatient Behavioral Health providers are licensed psychologists or psychologists who provide mental health counseling to Medicaid recipients.In light of the recent mass murder in Connecticut, I believe that most people would agree that the ability for anyone to receive mental health services is of utmost importance. In my opinion, mental health services are the most needed and most under-used health care service.  In the debate between guns and violent video games, I say that mental health issues and mental health care services trump both.  Create a society in which mental illnesses are (not necessarily accepted) but not stigmatized, people are comfortable asking for help regarding mental illnesses, people can identify others who are in need of counseling, and all people, no matter their insurance coverage,  have access to mental health care services.  Create this society and this society equals violent crimes under control.  A society in which a gun is merely a gun. For hunting, protection of family, or sport…not a weapon of mass destruction.  Mental health awareness is the key.

Ok, enough of my soap box.

In North Carolina, Outpatient Behavioral Health providers are bound by NC DMA Clinical Coverage Policy No. 8C.  Policy No. 8C is much shorter in length than most clinical policies. It’s terseness is a thing of beauty for the Outpatient Behavioral Health providers.

Herein lies tip #6:

Because 8C is so short, so terse, all Outpatient Behavioral Health providers should print off Policy No. 8C and fasten it onto the walls of the office (at least the meaty portions…not the beginning and ending fluff).

Outpatient Behavioral Health providers should have Policy 8C memorized.  Outpatient Behavioral Health providers should dream about Policy 8C.  Outpatient Behavioral Health providers should be able to regurgitate the meat of Policy 8C   …..I mean, come on, people, Policy 8C is 31 pages.  Without the fluff (just the meat) Policy 8C is only, in my opinion, 10 pages of meat…10 pages (pages 7-17)!!!! If the Outpatient Behavioral Health providers memorize a mere 10 pages, the Outpatient Behavioral Health providers will be able to thwart potential reconsideration reviews. Even if the State threatens or begins a reconsideration review, if the Outpatient Behavioral Health providers have memorized these 10 meaty pages, the Outpatient Behavioral Health providers will easily be able to defend the reconsideration review based on documentation and, thus, avoid any alleged overpayments. (After page 17 is important to follow in practice: it consists of billing codes and revisions to past policies, but 17-31 is not the “meat” regulating Outpatient Behavioral Health providers).

For this blog, I am concentrating on Section 7.3.3.  Section 7.3.3 is, by far, the biggest reason Outpatient Behavioral Health providers get dinged in Medicaid audits….BY FAR.  Service notes….really? YES.

Service notes are detail-oriented. Tedious. And one mistake on a service note…I mean a SMALL mistake…will cause the State to attempt to recoup the Medicaid payment bestowed for the entire service rendered. For example, an Outpatient Behavioral Health provider gets prior authorization from the correct state-contracted entity , a valid referral by a Carolina ACCESS primary care physician, a signed consent by the Medicaid recipient, a regulatory-correct Comprehension Clinical Assessment, a valid Treatment Plan and Service Plan… BUT….on the service note for one day…one couseling session….forgets to describe the Medicaid recipient’s reaction to the counseling. Or forgets to put the duration of the session (writes 6pm, but forgets to write that the session ended at 7pm). Or forgets to describe the nonverbal journal-writing session and bills for the play treatment (a higher-reimbursable code). What happens? A Medicaid audit.

According to Policy 8C, there must be a progress note for each treatment encounter that includes the following information (And, people, this is NOT difficult. This is the minimum and easy to meet):

  1. Date of service;
  2. Name of the service provided (e.g., Outpatient Therapy – Individual/Family Tx);
  3. Type of contact (face-to-face, phone call, collateral); non-face-to-face services are not covered and not reimbursable;
  4. Purpose of the contact (tied to the specific goals in the  Tx plan);
  5. Description of the treatment or interventions performed. Treatment and interventions must include active engagement of the individual and relate to the goals and strategies outlined on the individual’s plan;
  6. Effectiveness of the intervention(s) and the beneficiary’s response or progress toward goal(s);
  7. The duration of the service (e.g., length of the assessment or treatment in minutes; Pharmacological Management does not require documentation of the duration of service); and
  8. Signature, with credentials, degree, and licensure of clinician who provided the service. Electronic signatures must adhere to DMA guidelines. A handwritten note requires a handwritten signature; however, the credentials, degree, and licensure may be typed, printed, or stamped.
  9. Service notes must be written in such a way that there is substance, efficacy, and value. Interventions, treatment, and supports must all address the goal(s) listed in the plan. They must be written in a meaningful way so that the notes collectively outline the beneficiary’s response to treatment, interventions, and supports in a sequential, logical, and easy-to-follow manner over the course of service.

Is this difficult? No. Not rocket science.  I suggest creating a template. The template should have a space for every required component of the service note. Print off hundreds…no thousands.  Keep the print-offs in a location that all employees, if present, know of and make them understand that every service note must adhere to the template. Completely. No short-cuts.  No…”I forgot.”  Follow the template.

The result?  The Department of Health and Human Services (DHHS) or any of its entities or contracted companies will be able to audit any service note, written by any employee or you, and say, “This Outpatient Behavioral Health provider has met the minimum requirements of Policy 8C; therefore, there is no reason to try to recoup Medicaid funds from this provider. This provider has followed the rules.”

Wow. Shock and awe. Could that happen? Yes: MEMORIZE THE MEATY 10 PAGES OF POLICY 8C!!!!! And you too could avoid Medicaid recoupments.