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Ciara Zachary's picture

Strong health insurance is at the core of ensuring that children and their caregivers have access to effective physical and behavioral health services. Child advocates, take note: Medicaid, the health insurance program for over 1 million North Carolina children, is in the midst of a full-scale “transformation” that will have major implications for child and family health in the coming years.The process to transform North Carolina’s Medicaid and NC Health Choice programs officially began three years ago with the passage of Session Law 2015-245. Here are three things you should know about the Medicaid transformation process that is now underway:

1. Shift from fee-for-service to managed care. Currently, North Carolina’s Medicaid program is mostly fee-for-service. This means that Medicaid providers receive payments for each test, service, screening, and procedure that is covered. Medicaid transformation will change the program to a mostly managed care model. Under this new model, the Department of Health & Human Services will work with companies – commonly called managed care organizations or prepaid health plans – who will receive a set amount each month to cover health care for each person enrolled in Medicaid. Many believe that Medicaid managed care promotes cost-effective and efficient care, because of the focus on quality over quantity of services. However, poorly run managed care systems can and have resulted in companies denying needed services to consumers to make a profit.

2. Prioritizing the needs of children. The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit is essential for children with Medicaid coverage. EPSDT is a federally-mandated benefit that guarantees that children get the right care at the right time for all medically necessary services. It is designed to assess, diagnose, and treat children’s health care needs early and consistently to ensure that health concerns do not worsen – or can be averted altogether. Unfortunately, services on the ground don’t always fulfill the EPSDT benefit. We hope that transformation improves upon the implementation of the EPSDT benefit and works to ensure that children get the care they need, as mandated by law.

3. Timeline. The expected launch date for Medicaid transformation is November 2019. However, there are many steps along the way before Medicaid managed care actually begins. Potential prepaid health plans have to submit proposals to NC DHHS by October 2018. The Department is expected to award contracts in February 2019. Finally, the state is still waiting for final approval of the transformation plan from the federal government – while that is expected to come well ahead of the anticipated November 2019 start date, there have already been several delays in approval.

At NC Child we’re working to make sure that the Medicaid program continues to provide access to high-quality care for kids and families. That means making sure caregivers and families have the resources they need to navigate a new system; watching out for vulnerable populations, like pregnant women and young children; and ensuring that managed care companies adhere to the legal requirement that children receive medically-necessary care in a timely fashion. I will be monitoring the transformation process to make sure the needs of children and families are not overlooked, and NC Child will bring you periodic updates and opportunities for action – so stay tuned.
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