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Post-Sequester Cuts, the ACA, and the Federal Government: Damning Effects on Medicaid

One week has passed since the infamous federal sequester deadline. Let’s re-assess: Does the Sequester Affect Medicaid?

Remember, according to the federal government, the Medicaid budget was exempt from the across the board slashes in budgets.

However, the following sequester cuts will have a direct effect on Medicaid:

  • $44 million cut from the Centers for Medicare and Medicaid Affordable Insurance Exchange grants;
  • $168 million cut from Substance Abuse and Mental Health Services Administration;
  • $75 million cut from the Aging and Disability Services Programs;
  • $17 million cut from Housing Opportunities for Persons with AIDS;
  • $19 million cut from Housing for the Elderly;
  • $57 million cut from the Health Care Fraud and Abuse Control;
  • $51 million cut from the Prevention and Public Health Fund; and
  • $27 million cut from the State Grants and Demonstrations.

Let’s analyze the first cut: $44 million from the Affordable Insurance Exchange.  The Affordable Insurance Exchange grants is an intregal part of the Affordable Care Act (ACA).  The ACA directs the U.S. Department of Health and Human Services (“HHS”) to provide states with funding to support planning, implementation and operation of state exchanges.  Already every state except Alaska received an initial allotment of up to $1 million in planning grants  in the fall of 2010. North Carolina already received $86,357,315.

As I am sure everyone is aware, NC has opted out of Medicaid expansion.  However, the ACA requires an insurance exchange program.  On February 12, 2012, Gov. McCrory announced NC’s intent to allow the federal government to operate the exchange.

So, now, our health care exchange program will be only as good as the federal government makes it, which is a scary prospect in my mind, especially in light of the near certain fact that the federal government is in such financial stress that it will not be able to uphold its end of the bargains under the ACA.  Already?

I wonder if the states accepting the federal dollars for Medicaid expansion are re-thinking those decisions.

Last week, Charles P. Blahous, III, who has served as a public trustee for Social Security and Medicare since 2009, said there was a “near certainty” that the federal government would not provide the full level of Medicaid funding now scheduled under law.

Blahous  also stated that “to return the federal budget to sustainable historical norms in the absence of any cuts in the growth of Medicaid and the new health exchanges would require all other non- interest spending to be cut by nearly one-quarter by 2037 relative to projected levels, and by roughly 15 percent relative to current levels in relation to GDP.”

And: “This is probably unrealistic.”

Despite the budget cuts due to the sequester, the federal government is STILL in severe financial stress.

So as to, the ultimate question posed in the beginning: “Does the Sequester Affect Medicaid?”

The answer: A resounding yes.

Summary: (Please note: The word “impact” should carry a pejorative connotation. When reading, feel free to add in “negatively” each time you read “impact.”)

The sequester impacts health care. Medicaid is health care.  The sequester impacts Medicaid.

The sequester impacts the health care exchange program. The federal government is in financial stress. The federal government will control NC’s health care exchange. NC’s health care exchange will be in financial stress.

Shortage of Dentists for Medicaid Recipients

I’ve blogged before about the shortage of dentists for Medicaid recipients. Just see my post “Medicaid Expansion: BAD for the Poor” to read about Deamonte Driver’s story and why he died due to not being able to find a dentist accepting Medicaid. But, today and yesterday, I decided to conduct my own personal investigation.

(First, let me assure you that this blog is not condemning dentists for not accepting Medicaid recipients.  I am informatively (I know, not a word) pointing out the facts. We cannot expect dentists to accept Medicaid when the Medicaid reimbursements dentists receive cannot even cover their costs.)

I googled “Raleigh dentist” and called, randomly, 20 dentists listed.  I said the same thing to each receptionist, “Hi. I was wondering whether you accept Medicaid.” Every office had a receptionist answer (no recording asking whether I wanted to continue in English or Spanish). Every office receptionist was very sorry, but the dental practice did not accept Medicaid. 0. Zero out of a random 20.

So I went on North Carolina Department Health and Human Services’ (DHHS) website for dental providers. I pulled up the dental providers, and, lo, and behold, 44 pages were full of dental providers for Medicaid recipients. Literally, 1,760 dental providers are listed (44 pages times 40 lines per page). (However, some practices are listed more than once, so this number is an approximation).

I thought, Wow. Tons of dentists in North Carolina accept Medicaid.  Then I looked again.  On the far right side of the chart, there is a space for whether the dental practice is accepting new clients. Roughly 1/2 of the listed dental providers are NOT accepting new Medicaid clients.

I called a few of the dentists in Wake County accepting Medicaid.  Again, I asked whether they accepted Medicaid.  One stated, “Yes, but not at the moment.”  Another said, “Yes, but only for children 21 and under.”  Another gave a blanket, “Yes.

So that’s Wake County…what about more rural counties?

I called a few dentists in Union County. Two practices did not answer. One dental practice answered and gave me a “Yes.” According to the DHHS chart of Medicaid-accepting dental providers, 20 dentists in Union County accept Medicaid.  4 of which are not accepting new clients and one dental practice is listed as the health department.  There are no orthodontists in Union County accepting Medicaid.

The phone numbers for two dental providers in Swain County were changed or disconnected. There are only 3 dental providers in Swain County. There are no orthodontists in Swain County.

There is only 1 dental provider accepting Medicaid in Pamlico County.  According to the DHHS chart, the one dental provider is not accepting new patients.  There are no orthodontists in Pamlico County.

Polk County lists 3 dentists accepting Medicaid, but not one of the dentists are accepting new clients.  There are no orthodontists in Polk County.

Mitchell County has 4 dental providers acccepting Medicaid.  But 3 of those dental practices are not accepting new clients.  There are no orthodontists in Mitchell County

In Clay County, the only dental practice accepting Medicaid recipients is the health department.

In Ashe County, there are 3 dentists listed that will accept Medicaid.  Only 2 are accepting new clients, one of which is the health department.  There are no orthodontists in Ashe County.

In Alamance County, there are 4 dentists listed by DHHS who will accept Medicaid patients.  The first one I called (an orthodontist) told me that they accepted Medicaid patients only from certain general dentists.  The second one was not accepting new patients.  The third one (also an orthodontist) informed me that Medicaid does not cover orthodontia services for Medicaid recipients over 21 (I must sound old!!!) The fourth dental practice’s voicemail informed me that the office is only open Wednesdays and Thursdays  for limited times. Of the 4 dental practices accepting Medicaid, 3 were orthodontists, one did not accept new clients.  The only general dentist (pediatric) only practiced in the local office two days a week.

Shortage of dentists accepting Medicaid? You decide.


Obama Voices the Need for Access to Mental Health Care: Medicaid Recipients, Too?

Two days ago, Obama voiced that gun control and mental health care reform is on the horizon.  Since the terrible massacre at Sandy Hook Elementary School, people, especially politicians, have been talking about gun control.  The thinking behind this is that if the shooter at Sandy Hook did not have access to guns, the murders would not have happened.  Agreed.

But think of this:  If a child puts his or her finger in a light socket and gets electrocuted, do we cut off the power to the entire house forever? Or do we educate that child so he or she does not do it again?

Personally, I opt for the latter:  Educate.

If the child is incapable of understanding the concept of getting electrocuted by placing his or her finger in a light socket (i.e., the child has mental health issues), then, as a parent, I would seek mental health services for my child.  I still would not opt to cut off the power in the house.

Mental health services are vital.  Mental health services are important for all people. But since this is a Medicaid blog, I will focus on mental health services for Medicaid recipients.  Medicaid recipients need access to quality mental health services. Quite possibly, in the world of Medicaid, mental health services may be the most needed and least provided to recipients (maybe dental and specialities in medicine are also in the top most needed and least provided, but I will cover those topics in another blog).

I’m not talking about mental health services for the autistic children or children suffering from an easily diagnosed and highly recognizable mental health illness. These children obviously need mental health services.  In my opinion, most people would agree as to the need for mental health services to these children.  No, I’m talking about the thirteen year old girl who has so much anger built up inside that she begins to cut herself, torture animals and scream at her teachers. Or the 14-year-old boy, who was sexually abused by his uncle and is now exploring the sexuality of the 6 and 7-year-old boys in the school  bathroom. The 12-year-old boy who has no friends, is isolated at school, and is publicly ridiculed until he begins to think he has no reason to live and begins fantasizing about killings, both of himself and others…the ones who ridicule him.

Would wonderful access to mental health services for Medicaid recipients have stopped Sandy Hook from happening? Probably not. But future tragedies can be stopped by providing quality mental health services to all, especially to Medicaid recipients.  According to Obama’s recent speech, Obama agrees that quality mental health care needs to be accessible to all people.  But does that also mean Medicaid recipients? Medicaid recipients must meet criteria to receive therapy (after a certain number of visits).

Medicaid recipients rely on the Medicaid system for mental health services. I don’t mean to state the obvious, but think about it. People with private health insurance have choices about therapists. I can say, “I’m feel like my depression is overwhelming.” And schedule a psych visit for the next week. Not Medicaid recipients. Medicaid recipients need (for the most part) prior authorization. Which means if a Medicaid recipient feels low…really low…as in, needs a psychiatrist low, they need permission from the State.   A State-contracted agent must review the documents and determine it is medically necessary for that Medicaid recipient to receive therapy.  Although, for Outpatient Behavioral Services,

This is the criteria for a Medicaid recipient to receive Outpatient Behavioral Services:

Entrance Criteria

ALL of the following criteria are necessary for admission of a beneficiary for outpatient treatment services:

a.   A Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,Text Revision (DSM-IV-TR) (or its successors) Axis I or II diagnosis.

b. Presentation with behavioral, psychological, or biological dysfunction and functional impairment, which are consistent and associated with the DSM-IV-TR (or its successors) Axis I or II diagnosis.

c. Does not require a higher level of care.

d. Capable of developing skills to manage symptoms, make behavioral changes,and respond favorably to therapeutic interventions.

e. There is no evidence to support that alternative interventions would be more effective, based on North Carolina community practice standards (e.g., Best Practice Guidelines of the American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, American Board of Addiction Medicine).

Medicaid beneficiaries under 21 and NCHC beneficiaries are allowed 16 unmanaged visits; adults are allowed eight unmanaged visits per calendar year. All visits beyond these limitations require prior approval.

More than eliminating guns (or cutting the power off in the house), Medicaid recipients need somewhere to go to receive quality health care with no judgment and not all this criteria. If a Medicaid recipients wants to attend weekly therapy sessions, shouldn’t the Medicaid recipient be able to go to therapy without needing an Axis I or II diagnosis? Why does a Medicaid recipient need to be diagnosed with an Axis I or II diagnose in order to receive outpatient therapy?

So now Obama has publicly announced that, along with gun control measures, he plans to tackle the issue of mental health care.  I ask, “How?” and “Does this include access to therapy for Medicaid recipients?” The fact is that Medicaid recipients can see a therapist 16 (if a child) and 8 (if an adult) times. But then, the Medicaid recipient must show medical necessity in order to receive therapy. Is this quality mental health care? Is this access to quality mental health care for ALL?


Medicaid Fraud in NC

The NC Attorney General’s office has arrested 18 health care providers for Medicaid fraud in the last few weeks. Roy Cooper says more are to come in the upcoming weeks.

Those arrested include the following:

  • Andora Hailey, a Wake County mental health provider, is charged with four counts of Medicaid provider fraud. Investigators allege that she submitted more than $25,000 in bogus time sheets for payment.
  • Sarina Hotka, operator of a Cumberland County health care agency, is charged with eight counts of Medicaid provider fraud. Investigators allege that she billed the Medicaid program for more than $150,000 in unauthorized personal care services.
  • Gloria Rogers, a Cumberland County speech therapist, is charged with seven counts of Medicaid provider fraud. Investigators allege that she billed the Medicaid program for more than $50,000 in services she wasn’t licensed to provide.
  • Cynthia Denise McLean, operator of a Harnett County home health care agency, is charged with three counts of Medicaid provider fraud. Investigators allege that she submitted more than $8,000 in bogus time sheets for payment.
  • Geralyn Brown, operator of a Robeson County home health care agency, is charged with two counts of Medicaid provider fraud. Investigators allege that she submitted more than $1,000 in bogus time sheets for payment.
  • Timothy Batts, operator of a Wayne County group home, is charged with five counts of Medicaid provider fraud. Investigators allege that he billed the Medicaid program for more than $20,000 in unauthorized services at his group home and billed for services to Medicaid recipients that were not provided.

Cooper said that the above-listed arrests accounted for over $500,000 of Medicaid fraudulent payments.