What North Carolina’s Medicaid Transformation Means for the Healthcare Community

A career in healthcare means a lifetime of patience, learning, and processes. Healthcare professionals in North Carolina who are learning about the state’s Medicaid transformation will have to apply all three of those attributes moving forward. The NC Medicaid transformation has considerations for patients and professionals alike, so it’s important to be up to date on the changes.

On July 1, 2021, the state’s Medicaid program moved from a state-managed, fee-for-service system to a managed care system. The goal is to reduce for-profit health care costs and improve the quality of care for low-income patients. In other words, the burden of keeping costs low will now shift from the state to insurers and providers. The changes have been expected since the state general assembly passed Session Law 2015-245 six years ago.

How will it affect care?

The program will incentivize providers to select less costly forms of care for patients while attempting to improve access, efficiency, and equity. For example, doctors could use more resources on a proactive treatment for a patient’s blood sugar instead of paying for constant testing.

North Carolina had previously been the largest state without a managed care system for its Medicaid program, according to Carolina Public Press, so it is clear that these changes will have a large impact for all involved.

Patients may need additional time to understand policies

Almost all of the state’s Medicaid recipients are expected to be affected by the changes. According to an interview with NC Health News, state Medicaid Director Dave Richard knows the transition will be bumpy.

Healthcare professionals should expect patients to encounter a learning curve in understanding their new plan. While many standards and procedures of care for Medicaid had been in place for years, the NC managed care program will change this. Recipients can currently choose from five new plans to fit their needs.

Patients may need additional time with doctors or administrative staff as they become familiar with new plans, including more time spent explaining the types of care available and the process of obtaining it. Patients may also be seeing an entirely new doctor or new facilities as insurance companies offer different networks and providers. Patients may also choose to delay or avoid critical care due to confusion or lack of familiarity with the plans, so providers must stay in touch with their patients throughout the switch.

How can providers learn more?

NC Medicaid is attempting to ease the administrative burden to providers by standardizing processes wherever possible, using standard authorization forms, and covering medically necessary service fees. Ultimately, NC Medicaid wants to ensure that patients get the care they need, and providers get paid as quickly as possible. Additional resources are available at the state’s website: https://www.medicaid.ncdhhs.gov/transformation and on our previous article “North Carolina Medicaid Transformation”.

Despite the massive changes brought on by the NC Medicaid transformation, the state’s healthcare community remains committed to providing the highest quality of care possible to patients.

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