On July 14, 2020, we wrote a Blog on Medicaid Fee-for-Service Expansion. In the blog, we mentioned that even before the pandemic, Missouri, Oklahoma, as well as North Carolina and Kansas were considering the benefits of Medicaid expansion. Unlike other states, North Carolina was considering a transition to managed care rather than a fee-for-service expansion. Ranked the ninth-largest Medicaid program in the nation, and the largest that has not outsourced their program to managed-care companies, North Carolina is perceived as a goldmine for managed-care companies aiming to gain the Medicaid population.
The Medicaid program was scheduled to transition to managed care in 2019 but the issue of expanding the program to cover thousands of uninsured adults kept the governor and the legislature from coming to an agreement over a state budget.
On June 26, 2020, The North Carolina legislature passed a Medicaid transformation bill to not expand their fee-for-service but rather continue the transition from fee-for-service to privatized managed care organizations.
The bill includes a mandate to make the transformation happen by July 1, 2021. Other provisions in this bill:
- Allocate funds to local mental health management agencies for COVID-19 behavioral health and crisis services;
- Allow departmental funds for testing staff members at long-term care facilities, who often lack insurance coverage;
- Allow some of those funds to be used for hiring temporary contact tracing staff at local health departments;
- Allocate money to fund the department’s work on transformation in the coming year, which will fund the rehire of contractors to complete work on IT, program design, and fraud detection functions;
- Set a minimum rate for durable medical equipment.
The state has already contracted with five Medicaid managed care organizations to administer the transformation: AmeriHealth Caritas North Carolina, Inc., Blue Cross and Blue Shield of North Carolina, UnitedHealthcare of North Carolina, Inc., WellCare of North Carolina, Inc., and Carolina Complete Health.
GIRS continues to track Medicaid expansion to develop targeted payer relations strategies. Nebraska is transitioning and Missouri and Oklahoma voted to expand their Medicaid by July 2021.
GIRS’ Targeted Medicaid Payer Advocacy Work in North Carolina for #Medtech
In 2019, GIRS worked with the North Carolina Medicaid FFS program to research and analyze guidelines and fee schedules. We also worked with the payer to support payer dossier review to implement positive coverage for a #medtech Product. Our work was interrupted due to the impending Medicaid managed care transition in 2019. In 2020, we tracked the NC transformation initiatives and renewed our efforts to work with the Medicaid FFS program to conduct payer relations work to obtain positive coverage and appropriate payment implemented prior to the impending 2021 transformation. We also are working with the Medicaid MCOs on transformation details as they impact our clients.
Why Partner with GIRS?
As more of their clients become Medicaid recipients and as Medicaid managed care expands, GIRS is #LookingAheadoftheCurve by educating clients about the potential impact on their payer mix and redefining payer market access strategies to secure Medicaid coverage and preferred status for their products.
We currently are working with all Medicaid Fee-for-Service programs educating them about the clinical and cost data for our client’s Products and assisting with the appropriate pricing of these Products. We also are working with Medicaid managed care plans to advocate for coverage and appropriate payment.
The GIRS Payer Advocacy Compass PAC® team has over 17 years of experience tracking payer market trends and policies and educating providers and stakeholders about changes to ensure coverage and reimbursement of our clients’ medical technologies.
Please contact us by email or avail or avail of our Complimentary Review of your reimbursement needs at girsinc.com
Source:
About GIRS
For more than 17 years, GIRS has been assisting medical technology manufacturers with their market uptake and reimbursement strategies so that patients can have access to the care that they need. To implement successful market access strategies, the GIRS Value Discovery Landscape Assessments® team and the Payer Advocacy Compass® team work together to develop and implement foundation reimbursement landscape and payer advocacy strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake.
For more information, email us at info@girsinc.com or call us at 901-834-9119.
Disclaimer: The information in this blog is based on payer information which is dynamic. It is accurate at the time of posting but should not be construed to be reimbursement or legal advice. CPT® is the trademark of the American Medical Association (AMA).