Medicaid ‘a bear’ for Health Department

By Chris Berendt Staff Writer

April 18, 2014

Issues with Medicaid, especially those concerning undocumented pregnant women, have cost the county an estimated $13,000 just in the first quarter of 2014 alone, Sampson County Health Department officials say.

“Medicaid has been a bear for us this year,” health director Wanda Robinson told the Board of Commissioners earlier this week.

In no area has it been more of a bear than presumptive Medicaid, the period during which pregnant women are eligible to receive emergency Medicaid up to two months.

“When our undocumented clients come into our building we could, at one time, make them presumptively eligible and they could get services up to 60 days depending on the day they signed up,” Robinson said. “We got a memo (in late December 2013) that it was going to change as of Jan. 1, 2014, and we had no choice but to change with the system.”

That change was that those patients who were undocumented or illegal could not receive presumptive Medicaid.

Unlike some other private entities, the Health Department — called a “safety net” by Robinson — cannot turn people away for service, but at the same time those services are not free. Income has to be verified, at which point people are then placed on a sliding fee scale. Some may pay nothing, others may pay 20 percent.

“We have to look at their salary and what they have coming in. It may slide to zero, it may not,” Robinson remarked. “We will not be getting that pot of money this year. We’re not sure how that is going to impact us.”

Providing numbers, Robinson listed the tallies of prenatal clients covered by full or presumptive Medicaid for January-March the past three years. The total prenatal clients has increased along with those receiving presumptive Medicaid, the stats showed.

From January to March in 2012, there were 53 prenatal clients, 11 receiving full Medicaid and 42 presumptive Medicaid. In 2013, that rose by just one to 54, with nine receiving full Medicaid coverage and 45 receiving presumptive. This year, the total number of prenatal clients covered by Medicaid ballooned to 70, with 22 full Medicaid recipients and 48 presumptive.

“You can see we have already had 70 prenatal clients come through — 22 had full Medicaid, 48 were presumptive-eligible,” Robinson pointed out. “That 48, as of January, are not going to get any kind of Medicaid or anything. We put them on our fee schedule and if they slide off, they slide off. If not, then we collect 20 percent. It is wherever they slide on that sliding fee schedule.”

“This is very significant for us,” said Robinson. “We think the potential loss (of revenue) is about $13,000 for the first three months. We’re not sure. We still won’t know because, when they start in January, we don’t bill until after they deliver. The impact still won’t be seen until nine months down the road. We probably won’t know the impact until October or November.”

“Are you saying that the loss to the county is because we can’t deny the service? We have to provide it and Medicaid is not going to pay for it,” said Commissioner Albert Kirby.

Health Department officials said that was correct.

“From what we understand, somebody (at the state) forgot to check a block for presumptive eligibility, therefore this piece was left out,” Robinson noted. “They’re trying to get it back in, but as we understand it is much, much easier to forget to check a block than to get it back in. It’s going to take a legislative order to get it back to what it was.”

A Supreme Court ruling on the Affordable Care Act (ACA), known as Obamacare, allowed states to opt out of the law’s Medicaid expansion, leaving each state’s decision to participate in the hands of the governors and state leaders. North Carolina opted out of the expansion, along with 23 other states.

“Had the governor and the Legislature opted-in in the expansion, Sampson County would be in a much better position in terms of those people being eligible, is that correct?” Kirby asked.

“That is correct,” Robinson noted.

DSS director Sarah Bradshaw said it might not be that simple, as the local workforce would likely have to be doubled, as more resources and additional outreach would be required. Robinson noted that the state could still choose to opt-in.

“Especially with our presumptive eligibility, please. That is very significant for us,” Robinson told commissioners. “Of all the things that have hit us, that has been the most significant piece. We would be mandated to provide that service (at county cost). It is going to be significant. We need to talk to our legislators. That is the only way we’re going to get it changed. I have had conversations with them, but you’re going to have to help me, because this is significant. We have a really high migrant population in this county and this is very significant for us.”

No matter what happens, she said, the undocumented sector of the population will not be fully covered, but their children could be. And some assistance in the area of presumptive Medicaid would help a great deal, she stated.

“If we can get those women prenatal care, if that child lives here in Sampson County, they will be counted as a resident and they can apply for Medicaid and will probably get it, but you have to get them through prenatal care here before they can get on the system and get healthcare,” she said.

“We’re not in the business of looking at immigration,” Robinson continued, “that is not what we’re about. I just want to provide health services to those who need it in an economical and good way.”

On top of the presumptive eligibility issues, there have been growing pains with N.C. Tracks, the new multi-payer Medicaid Management Information System for the N.C. Department of Health and Human Services.

“We had big issues with N.C. Tracks. It took us about two months to work through the system to get our first payment. It has been an uphill battle from July 1 until now,” said Robinson.

She credited Health Department employee Tamra Jones and her staff with working diligently to keep money flowing and ensure proper codes were keyed in.

“It has not been a simple task,” said Robinson, who noted that the system change resulted in two to three months without payment. “We are almost to a place now that we feel pretty good about it. We’re still in the process of rebilling denials.”

And just last week, the local Health Department received a memo that effective July 1, there is going to be a 3 percent reduction in reimbursement rates for a number of services rendered to Medicaid and N.C. Health Choice beneficiaries.

“We’re not sure if they are going to exempt us or not,” said Robinson. “We’re not quite sure yet as to whether or not that is going to affect us. We’re already behind the eight ball.”

Chris Berendt can be reached at 910-592-8137 ext. 121 or via email at