North Carolina preps for challenges of Medicaid expansion

Fifty-four percent of people in this rural community — home to 116,530 at the 2020 Census — are beneficiaries of the government-funded program. The county had 63,549 Medicaid enrollees in October, the eighth highest number recorded of the state’s 100 counties.

Even more are expected to join the rolls after Medicaid expansion takes effect on Dec. 1. The long-awaited measure will raise the state’s income limit for Medicaid, extending eligibility to hundreds of thousands of North Carolinians who make 138 percent of the federal poverty level or less.

Single adults, a population that was effectively ineligible for coverage before expansion, will qualify if they earn less than $20,000 a year. The threshold increases by $7,094 for each additional household member, meaning a person with a family of four would qualify if their annual income is less than $41,400.

Expansion will be particularly impactful in economically distressed areas like Robeson County, where the median household income is less than $37,000. Many people in Robeson who are not currently enrolled in Medicaid have no health insurance at all.

This year’s national County Health Rankings report from the University of Wisconsin Population Health Institute found that 20 percent of the county’s residents are uninsured — higher than the statewide average of 13 percent. The report also ranked Robeson as the least healthy county in North Carolina.

The work of managing the county’s anticipated surge in Medicaid applications will largely fall on the Robeson County Department of Social Services.

Gene Downing, who oversees Medicaid enrollment for Robeson County DSS, said the department has hired more people to handle the workload. The agency is also in the process of creating a call center to help residents with questions about eligibility.

“There’s a little bit of fear because it’s a new policy that we’re trying to learn [while still] managing everyone that we already had,” Downing said.

Expanding amid ‘unwinding’

The N.C. Department of Health and Human Services knows that local agencies such as Robeson County’s DSS will play a crucial role in implementing expansion.

In a letter to county managers and DSS directors issued on Friday, DHHS deputy secretaries Jay Ludlam and Susan Osborne acknowledged that the “important work to expand health coverage across our state begins at local DSS offices.” The state, they wrote, is “focused on providing policy changes, automation improvements, training opportunities, and financial support to help counties meet this increased demand.”

Ludlam and Osborne also noted that expansion comes as local DSS offices are dealing with the “unwinding” of the continuous coverage requirement, a federal mandate that prevented states from kicking Medicaid participants off the rolls during the first three years of the COVID-19 pandemic.

Medicaid benefits were automatically renewed while the provision was in place, even if a person no longer qualified for the program. The requirement expired shortly after the federal Public Health Emergency ended earlier this year, forcing social workers in North Carolina to verify the continued eligibility of 2.5 million enrollees for the first time since March 2020.

More than 162,000 North Carolinians have lost Medicaid since the state resumed terminations in June. About 141,955 of those people, or 87 percent, lost coverage from June to October for “procedural reasons,” according to the latest available data from DHHS. Procedural disenrollments typically occur when a local DSS office does not have all the information needed to verify a Medicaid participant’s current income and household size.

DHHS has said the state is making “many efforts to reach beneficiaries to get their information” during the unwinding, including through letters, emails, text messages and automated phone calls. But if a caseworker is using an outdated address or phone number, the beneficiary may never receive the message.

The state’s other 20,183 unwinding-related disenrollments involve residents who were deemed ineligible for coverage based on criteria that will change once expansion takes effect.

Many of these people are expected to qualify for Medicaid again under expansion.

Medicaid or Marketplace?

The situation can be vexing to expansion-eligible people who recently lost coverage.

Some have turned to the N.C. Navigator Consortium for guidance. The federally funded organization offers free consultation and support to people in need of health insurance.

“We have been helping folks since early summer who were affected by the unwinding, but still there’s a lot that’s happening in the Medicaid space in North Carolina right now, and that’s been one of our concerns,” said Nicholas Riggs, director of the consortium. “Is this going to be confusing for folks with so many different changes?

“Obviously, in the end, Medicaid expansion is absolutely a good thing as far as making sure that folks have access to coverage across the state and are covered under full Medicaid benefits and able to access doctors and essential services. But I think with just so many things happening at one time, it does lend itself to perhaps a little bit of confusion.”

Further complicating matters, North Carolina’s expansion date will coincide with the open enrollment period for health insurance plans through the Affordable Care Act. Many North Carolinians might be wondering if they should sign up for insurance now through the federal Marketplace or wait until Dec. 1 to apply for Medicaid.

Riggs, however, doesn’t see the overlapping events as an issue. On the contrary, he said, “they kind of compliment each other.”

“Folks who have heard about Medicaid expansion and want to see if they’re potentially eligible [may] find out that their income is projected to be above 138 percent of the federal poverty level,” Riggs said. “They haven’t explored the Marketplace before, so we’re able to help them enroll in a Marketplace plan with, a lot of times, a $0 premium.”

As for the people who do meet the new income threshold for Medicaid, Riggs said the consortium’s health insurance navigators can “reschedule them for an appointment” to apply for coverage after expansion launches.

“Having the two at the same time has definitely been more work for our staff,” Riggs said. “But as far as how it helps the folks across the state, I think the two kind of coinciding, from our perspective, has increased awareness around both Medicaid and the Marketplace. We are able to capture folks that maybe we wouldn’t have had this happened outside of open enrollment.”

‘A blessing’

Kody Kinsley, head of DHHS, said the state has “all hands on deck” to implement expansion.

“We’ve been working on this for a long time,” Kinsley said in an interview last week with NC Health News. “Every part of the department is involved and excited about this.”

Among other preparations, DHHS is conducting outreach to soon-to-be eligible North Carolinians and has beefed up its technology systems to handle the anticipated surge in activity when expansion launches. The agency has also been working to bolster the state’s provider network to ensure that new Medicaid participants have access to care.

On Wednesday, DHHS announced it was raising the minimum Medicaid reimbursement rates for behavioral health providers for the first time since 2012.The increased rates, which take effect on Jan. 1, will be permanent thanks to $200 million in recurring funds allocated by the General Assembly as part of this year’s state budget.

The first residents who will benefit from expansion are those currently enrolled in so-called Medicaid family plans, which offer fewer benefits than traditional Medicaid. DHHS estimates that 300,000 family plan enrollees will be automatically upgraded to full coverage.

Another 300,000 people are expected to join the rolls through the traditional application process for Medicaid. Kinsley said this can be done using the state’s ePASS website.

“Getting all of your application documents there and submitting is going to be the fastest way that people can get through the system because of all the technology that we’ve been able to put in place,” he said.

It generally takes about 45 days for Medicaid to kick in after a person is approved. But Kinsley said the benefits will retroactively cover medical expenses dating back to the first day of the month that the application was submitted.

“Your doctor is going to be able to bill us, and that’ll all be taken care of,” he said.

Despite all the work that has gone into preparing for expansion, Kinsley stopped short of promising a seamless rollout.

“I’m confident that we’re going to have a bolus of people that come forward … that is going to be larger than what the performance of the statewide system, as far as our staff and our DSS office, can manage all on one day,” he said, referring to the state Division of Social Services. “That’s normal for any type of new launch — any new product launch — that you bring out.”

Kinsley likened the state to an Apple store “with a line down the street” waiting to buy the latest iPhone. DHHS, he said, anticipates seeing “some full waiting rooms” once expansion goes live.

But Kinsley believes that’s a small price to pay to give working families the “peace of mind” that comes with having health insurance.

“It’s a blessing to these folks,” he said. “I’m so excited to be a part of bringing that blessing to 600,000 people on Dec. 1.”