Difficulties in working out deals with Atrium Health are a factor in the delayed implementation of Medicaid plans for people with complex behavioral health conditions.
In North Carolina, people on Medicaid used to receive care via a fee-for-service mechanism, by which the state reimbursed providers for services. But 18 months ago, the state shifted to Medicaid managed care. Beneficiaries now receive care from a standard plan offered by one of five insurance companies, which reimburse providers, while the state pays a fixed per-member cost.
Medicaid beneficiaries with complex behavioral and physical care needs will get care from a tailored plan offered by one of six organizations, called managed care organizations.
But the implementation of these tailored plans, which would serve about 143,000 people and offer the same services as the standard plans, in addition to more niche services, is once more delaying its implementation, this time from April 1 to Oct. 1, 2023.
The delay comes as Republicans in the state House and Senate have reached a deal on expansion of Medicaid to hundreds of thousands more low-income and needy people. GOP lawmakers have previously said the state’s move to managed care was a necessary step to be able to expand Medicaid.
Atrium Health contracting woes
The delay was largely due to none of the organizations providing what are known as tailored plans having a large enough provider network to meet needs, according to N.C. Department of Health and Human Services Secretary Kody Kinsley.
According to data presented by Kinsley on Wednesday to House and Senate lawmakers, between 20,000 and 30,000, or up to 20%, of tailored plan members would not have their current primary care provider in network. This could mean members would receive care from new providers, who could be farther away, and face difficulties scheduling nonemergency medical transportation, among other issues.
The local management organizations, which provide the tailored plans and which all had representatives at Wednesday’s meeting, said they were having difficulties contracting with Charlotte-based Atrium Health, which affects their network of providers.
Rob Robinson, chief executive officer with Alliance Health, one of the organizations, said though it met network requirements, “we still have one big holdout and that’s Atrium.”
“They’ve been at the table; they’ve been good to work with. We’ve just got to keep slogging through,” he said.
Rhett Melton, chief executive officer for Partners Health Management, which covers Western North Carolina but not Mecklenburg County, said many people outside of Mecklenburg get their care from Atrium Health, which Partners does not have a contract with.
This, Melton said, “displaces about 25% of our members, and we have been aggressive at trying to get the contract with Atrium.”
“We’ve agreed to all the terms that have been asked of us, and there are no disputed terms, but we still have not gotten across the finish line with that contract,” he said.
Challenges with health plans
Kinsley also said Wednesday that across tailored plans, there were operational system issues which could lead to providers not getting paid on time and more.
The department, Kinsley said, had looked into multiple ways to mitigate problems, such as allowing out-of-network billing, relaxing prior authorization requirements for services and more. Those were not enough, he said.
A spokesperson for Atrium Heath wrote that they were “deeply committed to serving this special segment of our population, which has very specific and unique needs. We continue to actively engage with the appropriate tailored plans and want to build a strong working relationship that will allow us all to serve patients better.”
“As part of that, we need to validate the plans are prepared for their responsibilities to fully and adequately serve the needs of their constituents. That’s especially true as coverage is now expanding beyond behavioral health. Based on its most recent assessment, the State of North Carolina has concluded there are numerable challenges in the submission, processing and payment of claims – which has been a historical challenge with these health plans,”
“Given the new start date of Oct. 1, the health plans have ample opportunity to evaluate their deficiencies and make the necessary improvements. Together, we have to make this process viable for all parties, especially the patients and their families.”
Sen. Jim Burgin, a powerful Republican lawmaker on health issues, on Wednesday noted the common denominator, saying “from what all we talked about, if we had somebody here from Atrium today that could sign a contract, we could go ahead and do this.”
“I’m not gonna put anybody from Atrium on the spot. But if you will see me right after this meeting, we will have a real quick meeting. And we can resolve a lot of this,” Burgin said.
Delay at the last minute
To pull in as many providers as possible, Kinsley said the department worked “right up until the line.”
Managed care organizations were not told about the decision to delay, which was announced Monday, until the last minute to “drive the pressure up” for contracting to happen, Kinsley said.
Asked by Rep. Larry Potts, a Davidson County Republican, why he thought the new October deadline would work out, Kinsley said that date “puts in a better window” for contracting and “we can work together with the committee to think about other strategies to mitigate risk and to compel various contracting that needs to happen.”
Rep. Donna White, a Johnston County Republican, also took issue with the delayed notification.
Wouldn’t it “have been a little bit more professional for” the managed care organizations “to at least have a heads up that you were thinking about doing this?” White asked. “This has been very – I will just use the word embarrassing – maybe humiliating for professional organizations that have worked very, very hard to be able to move forward in this endeavor which the department allowed them to do, to find out through the grape vines, before they even found out, in a direct manner from DHHS.”
“I just believe that when we’re working together as professionals, we all should act like professionals. Especially when we’re dealing with issues such as this. If there have been a couple of bad apples in the batch, then all of them should not be held accountable for that,” White said.
Kinsley replied that if word of the decision got out early, people may have walked away from the contracting table. He said that all six of the managed care organizations had insufficient networks.
“The decision that drove this not to move forward, touched every single one of them. There was not one that could have been ready,” Kinsley said.
Here’s the breakdown of need according to data presented Wednesday:
Alliance Health – Mecklenburg County: About 35,200 members would be enrolled with 11,000 members unable to select their historical primary care provider.
Trillium Health Resources – largely portions of Eastern North Carolina: About 24,500 members would be enrolled with 4,300 members unable to select their historical primary care provider.
Vaya Health – largely portions of Western North Carolina: About 24,400 members would be enrolled with 4,400 members unable to select their historical primary care provider.
Partners Health Management – largely portions of Western North Carolina: About 27,100 members would be enrolled with 8,600 members unable to select their historical primary care provider.
Eastpointe Human Services – largely portions of Eastern North Carolina: About 13,400 members would be enrolled with 2,300 members unable to select their historical primary care provider.
Sandhills Center – largely central North Carolina: About 19,100 members would be enrolled with 5,000 members unable to select their historical primary care provider.
Ames Alexander contributed to this report.