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Tag: Transition

  • Should North Carolina operate its Medicaid oral health program as fee-for-service or transition to managed care?

    Should North Carolina operate its Medicaid oral health program as fee-for-service or transition to managed care?

    By Anne Blythe

    As lawmakers ponder whether to expand Medicaid to add some 600,000 more people to the rolls, the North Carolina Oral Health Collaborative is looking at a different aspect of the federal- and state-sponsored insurance program.

    Nearly a year ago, North Carolina transformed its Medicaid program from a fee-for-service-based plan to a system managed by private insurers.

    The oral health portion of the program, however, was not part of the Medicaid transformation. It is still managed by the state.

    Zachary Brian, director of the North Carolina Oral Health Collaborative and vice president of impact, strategy and programs at the Foundation for Health Leadership and Innovation, said recently in a telephone interview that his organization has partnered with the North Carolina Institute of Medicine and The Duke Endowment to launch the Oral Health Transformation Initiative. (Disclosure: The Duke Endowment is a NC Health News sponsor).

    In July, a task force with members from diverse vantages in oral health care delivery will begin a year-long process in which members consider whether oral health care provided through Medicaid should remain a fee-for-service program or be overseen by private insurers.

    “The traditional fee-for-service payment system incentivizes costly, more invasive procedures,” Brian contended while announcing the joint initiative.

    “Nationally, we see a movement in remodeling our health care delivery system in many ways,” Michelle Ries, associate director of the North Carolina Institute of Medicine, added in the same video announcing the initiative. “As North Carolina has moved to managed care for primary health care and behavioral health services, we believe we owe it to the consumer and provider communities to thoroughly look at the current landscape for oral health and make recommendations based on an analysis of what other states are doing and lessons learned from the rollout of Medicaid managed care so far in North Carolina.”

    Whole-body care

    For too long, many public health advocates say, oral health care has been in a silo, of sorts, the mouth separated from the body. This is increasingly out of step with the systemic “whole-body” approach being advocated for more recently.

    A look into someone’s mouth can reveal evidence of heart disease, cancer, autoimmune syndromes, viruses, diabetes and gastrointestinal problems.

    Public health advocates say that integrating oral health care with primary care could not only make many communities and populations healthier but also reduce costs. People who do not have routine access to dental care often end up in emergency rooms with toothaches or infections in the oral cavity. Those visits can be far more costly for the patient, the provider and the insurer.

    Many communities in North Carolina face challenges accessing “optimal oral health care,” according to the Oral Health Collaborative.

    Four counties in North Carolina do not have a regularly practicing dentist, according to data collected from 2020 by the Cecil G. Sheps Center for Health Services Research. They’re in the northeastern tip of the state — Camden, Gates, Hyde and Tyrrell counties.

    Will more dentists participate?

    The collaborative says roughly 35 percent of the dentists in North Carolina participate in Medicaid or the Children’s Health Insurance Program, or CHIP as it’s often called.

    Dave Richard, head of Medicaid at the state Department of Health and Human Services, said his office puts that number closer to 40 percent. 

    Nonetheless, that number can pose a challenge for children and adults in need of care, often in the state’s rural reaches, public health care advocates note. Only 18 percent of adult Medicaid recipients in North Carolina use the dental care option, according to the collaborative’s statistics.

    Richard said that in 2021, the state’s fee-for-service Medicaid oral health program paid $24 million in claims for children in the CHIP program. The program paid $300 million for children ages 6 to 20 in the Medicaid program, and $104 million for adults 21 and older.

    Richard took no stance on whether it would be better to shift the oral health program to managed care or keep it as a fee-for-service program.

    Instead, he posed several questions.

    “What value add would you bring if you move to managed care?” Richard asked. He also wondered whether the state would lose or gain more dentists through such a shift.

    That’s what the task force plans to study over the next year with hopes of delivering a report and potential series of recommendations for a reimagined oral health care system. Their goal is to get something that policymakers and lawmakers can have to review in time to decide whether the state should make the shift before the next contracts are negotiated in 2024.

    “So often we don’t have the opportunity to really slow down and take a year, 18 months and dig in and engage with other states and engage with experts and really bring people to the table,” Stacy Warren, program officer for The Duke Endowment, said when the initiative was announced. 

    “We can’t just fund a lot of programs,” she said, although she said that’s actually happening. “We fund school-based oral health programs. We fund medical-dental integration programs, but what we’ve learned and the North Carolina Oral Health Collaborative has certainly helped teach us this over the years, is that these programs can’t exist successfully in isolation of true systems change.”

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    by Anne Blythe, North Carolina Health News
    June 14, 2022

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  • Months in, Medicaid transition still confusing patients

    Months in, Medicaid transition still confusing patients


    By Clarissa Donnelly-DeRoven

    About 1.7 million people in the state have experienced a change to their insurance in the seven months since North Carolina began its switch from a Medicaid system administered by the state to one managed by five for-profit organizations (and one by the Eastern Band of Cherokee Indians for tribal members). 

    Despite a marketing push and outreach efforts, a quarter of people with Medicaid didn’t know about the transition back in July according to a study from an advocacy group. And now, more than half a year in, data from the Medicaid Ombudsman’s office — which fields and investigates questions from people with Medicaid — show that thousands are still confused about the technically public insurance, which now looks and acts a lot like private insurance.

    Issues with education, access to care

    From June 27 through Nov. 27, the Medicaid Ombudsman’s office received more than 10,000 calls. This specific office is designed to support patients. A different agency helps providers, but it is also called the Medicaid Ombudsman — meaning, the 10,000 calls likely represent a mix of both patients and providers calling for help. 

    The Ombudsman opened cases for about 6,200 callers. Around 2,800 of those people reached out for general educational information, or to make a complaint. A good chunk called to change their plan, while nearly 10 percent called to discuss “access to care” issues and 184 people called about problems with non-emergency medical transport. 

    Bumps were expected during the start of the transition. Those at the state level have argued the change will be worth it for the budget predictability and improved health outcomes they believe will come under managed care. With the new system, the private plans receive a flat per-person rate, which state health officials argue will encourage the organizations to invest in whole-person health and lead to better health outcomes for patients.

    Still, some providers worry cuts to reimbursement rates will come in the future, which will lead fewer providers to accept Medicaid. Stacy Kozlowski, a pediatric occupational therapist in Johnston County, said she’s had increasing issues with service denials. 

    “Things were supposed to be unchanged for the first year. Already we’re seeing that’s not the case,” she wrote in a text.

    More than anything, people are worried that the neediest Medicaid recipients will be lost in the shuffle. 

    “From a business perspective we can survive,” Kozlowski said. “The increased overhead is burdensome, but the kids will suffer.”

    Geographic distribution

    Judging from the numbers to the Ombudsman, people across the state are struggling with the transition at similar rates, some rural residents more than others. Of Hyde county’s 696 managed care beneficiaries, 9 called the Ombudsman’s office — meaning, 1.3 percent of enrollees, the highest call rate. Similar rates are seen in Martin (1.15 percent) and Mecklenburg (1 percent) counties. 

    While some calls involved multiple managed care organizations, when broken down to include only calls involving individual plans, the greatest percentages came from those enrolled with UnitedHealthcare (.18 percent) and WellCare (.18 percent). The complaints represent a very small portion of overall members, though they are higher than complaint rates from the other managed care organizations across the state.

    The N.C. Department of Health and Human Services has documented other issues with UnitedHealthcare’s MCO plan. In September 2021, the department reported that 15 percent of people enrolled in United’s plan who live in eastern North Carolina do not have an in-network hospital within 30 minutes, putting it out of step with the standard plan network adequacy standards. 

    The state’s Medicaid dashboard lists each MCO and the top three reasons the organizations denied claims in November 2021. The data is broken down into claims submitted by smaller medical offices or solo practitioners (listed as professional claims), institutions, and pharmacies. Some of the most common reasons include failure to obtain prior authorization, service billed for not included within the contract, billing provider not enrolled in Medicaid and many more.

    There are two Medicaid Ombudsman: one helps patients navigate the transition to managed care, while the other helps providers. People with Medicaid can call 877-201-3750 on weekdays from 8 a.m. to 5 p.m. 

    Health care providers should contact [email protected] or 919-527-6666 with any questions.

    Of the denials listed, UnitedHealthcare, which covers the entire state, has the highest number at about 130,100 — nearly 30,000 more than the denials listed from the next highest MCO, Amerihealth Caritas, which also insures people statewide. 

    ‘Raise Your Hand’

    Before the transition, health advocates honed in on one predictable issue with the transition.  They were concerned that the 1 million people who are supposed to stay on the state-run Medicaid Direct — those with significant mental health needs, developmental disabilities, children in foster care, and people on certain Medicaid waivers — might be incorrectly switched to a managed care plan.

    “When we were working with the department on the implementation of all this, one of the things I raised with them was, how are you going to identify all these people?” said Doug Sea, the director of the Family Support and Health Care department at the Charlotte Center for Legal Advocacy. He’s worked in public benefit law since the 1980s. 

    One answer is the “Raise Your Hand” process: if a person was incorrectly switched to a managed care plan, they or their health care provider needs to fill out a form and request to be switched back. The Medicaid Enrollment Broker — another child of the managed care transition — is supposed to help beneficiaries with this process, along with any other person on Medicaid who has questions about how to choose a plan. 

    “Their job is to help people decide which plan to choose, or to help people change between plans, or to help people navigate this process of moving back and forth,” Sea explained. “Your circumstances could change — one day you’re in foster care, the next day you’re back with your parents. One day you need enhanced mental health services, the next day you don’t.”

    Do you have Medicaid? Send an email to [email protected] and tell me how it’s going: What questions do you have? What services are you struggling to get covered? Are there enough doctors in your area who accept your plan? I want to hear it all.

    Maximus, a for-profit company that earned $4.2 billion in revenue last year, was awarded a base $17 million contract with DHHS to be the Enrollment Broker in 2018. According to the company’s 2021 filings with the Securities and Exchange Commission, 39 percent of its revenue comes from state agencies.

    During the five months for which NC Health News reviewed data, 169 callers to the Ombudsman’s office requested to stay on Medicaid Direct, and 94 were referred to the “Raise Your Hand” process. 

    It’s not a huge number, but those who were supposed to be exempt from the managed care transition are those with significant needs, meaning that figuring out how to switch one’s self back to Medicaid Direct is yet another thing to do on a long list of needs. Luckily, once the process is initiated, a spokesperson from DHHS said the switch happens within 24 hours. 

    But, there’s still one more barrier: if a person’s Medicaid eligibility will soon be under review — as happens once a year — the automated system does not allow their transfer to be processed. 

    The Medicaid Enrollment Broker can be reached at 1-833-870-5500. This brochure lists the different agencies people with Medicaid can contact about various issues.

    “Beneficiaries who have not been redetermined [as] eligible are unable to make that change until after their redetermination is complete,” wrote DHHS spokesperson Summer Tonizzo. 

    “The way North Carolina [has] set up this system is very complicated,” Sea said. “We’ve seen a lot of cases where people are not in the right place, or their request to move back doesn’t get processed, or they don’t get written notice that their request has been denied, or their request got lost, or their request can’t be processed in time for them to get the services they need.

    “There’s just a whole host of ways this can go wrong,” he said.

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    Republish this article

    As of late 2019, we’re changing our policy about reprinting our content.

    You are free to use NC Health News content under the following conditions:

    • You can copy and paste this html tracking code into articles of ours that you use, this little snippet of code allows us to track how many people read our story.





    • Please do not reprint our stories without our bylines, and please include a live link to NC Health News under the byline, like this:

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    • Finally, at the bottom of the story (whether web or print), please include the text:

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    by Clarissa Donnelly-DeRoven, North Carolina Health News
    February 8, 2022

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  • Sleep Practice – Dr. Clifford Brown Announced Transition

    Sleep Practice – Dr. Clifford Brown Announced Transition

    Sleep Practice – Dr. Clifford Brown Announced Transition

    The staff at Babylon Dental Care has announced that exercise founder Dr. Clifford Brown will be transitioning from the dental side of the observe to operating his slumber observe, Silent Evening Remedy, whole-time. Dr. Brown, whose philosophy of affected person care is “treat clients like household,” has been serving to his patients boost their oral wellness for virtually 4 decades. Now, he’s shifting his aim total-time to his snooze apply and aiding people who go through from snooze apnea.

    Dr. Brown is a member of the American Academy of Dental Rest Medication (AADSM) and the Academy of Medical Rest Ailment Disciplines. Just after witnessing to start with-hand the quantity of sufferers struggling from slumber issues, Dr. Brown commenced to teach himself on these troubles and grew passionate about serving to these sufferers discover a better answer to their affliction.

    Even a 10 years back, neither physicians nor sufferers knew a lot about slumber apnea. In reality, numerous people struggling from the affliction wrote it off as insomnia or other health circumstances. The fact is, sleep apnea is a harmful condition that can lead to daily life-threatening overall health concerns like hypertension, body weight attain, exhaustion, problems, gasping for air while sleeping, loud snoring, episodes of not breathing when asleep, and even demise. According to the American Rest Apnea Affiliation, it is estimated that 22 million People are presently living with rest apnea.

    Now, in Dr. Brown’s watch, the basic community is eventually commencing to wake up to the pitfalls linked with rest apnea. Sleep apnea has been the result in at the rear of recent large-profile deaths, together with the death of Star Wars actress Carrie Fisher. As a final result, slumber and sleep apnea have come to be mainstream issues in both attention and value in recent yrs. In accordance to Dr. Brown:

    “Sleep has a renewed perception of relevance for people. We’re doing work more challenging than ever prior to, and below additional pressure than ever before. Receiving superior sleep is very important to our overall wellbeing.”

    Dr. Brown and the Silent Evening Treatment workforce have witnessed a big inflow of new sufferers. Dr. Brown attributes the maximize in appointments to a wide range of factors. The onset of the COVID-19 pandemic brought anxiety, building it a lot more tough for men and women to practice balanced slumber behaviors. And most a short while ago, Philips, the company of the CPAP device, recalled all CPAP units in June of 2021, citing safety concerns.

    For many years, slumber apnea had been treated by applying a CPAP machine, which can be loud, unpleasant to wear, and invasive. The CPAP essentially forces oxygen into a person’s lungs by delivering a constant and constant stream of air to a particular person whilst they sleep, which is an unnatural option to a all-natural overall health difficulty. CPAP units comprise a sound abatement foam that has been shown to disintegrate above time, leading to foam particles to move into the airway. At the time of the remember, Philips disclosed that severe health and fitness challenges had been related with use of CPAP units, which includes most cancers.

    The CPAP remember left thousands and thousands of slumber apnea people without having a usually means to take care of their ailment, which led several to seek out choice therapies these as those made available by Silent Evening Remedy.

    Dr. Brown, a slumber apnea affected individual himself, could hardly ever fully grasp why the CPAP product was considered the “gold standard”. As he furthered his schooling in Dental Rest Medicine and Oral Appliance Treatment, he started to target extra on serving to individuals suffering from sleep apnea obtain other choices to the noisy and intrusive CPAP product.

    Dr. Brown’s slumber therapy observe, Silent Night time Therapy, gives successful option solutions for snooze apnea sufferers. Dr. Brown was a person of the 1st dentists on Prolonged Island to suggest and make Oral Slumber Equipment (OSA) equipment. These wearable appliances look related to a mouthguard and are substantially less invasive than CPAP. OSAs treat rest apnea by shifting the jaw and somewhat opening the air passage. These personalized products are designed to in good shape pretty much any mouth. Even though numerous of Dr. Brown’s individuals are CPAP intolerant and have been beforehand identified at an additional business, Silent Night Therapy is entirely geared up to diagnose new clients who are struggling with their sleep. The workplace presents the affected person an at-residence slumber review, which is normally extra correct than an in-office environment snooze research simply because you can slumber a lot more very easily in your very own mattress, and with the success the group can diagnose no matter whether the individual has slumber apnea.

    In addition to Dr. Brown, Michele Sands, who has worked with Dr. Brown for extra than a 10 years, will be transitioning and getting on the role of Snooze Director at Silent Night time Remedy. As a lot more people today turn into conscious of rest-connected troubles, Dr. Brown hopes that he and his team will be capable to assist more clients get the balanced rest they need to have and ought to have.

    About Babylon Dental Treatment and Silent Night Treatment

    Babylon Dental Care has been serving the Extensive Island local community with great dental treatment considering the fact that 1983 with spots in West Babylon (785 W Montauk Freeway, West Babylon, NY 11704) and Patchogue (499 Sunrise Highway, Ste. 13B, Patchogue, NY 11772). Visit us online at www.babylondentalcare.com and call us at (631) 587-7373.

    A member of the American Academy of Dental Rest Medicine (AADSM) and the Academy of Scientific Rest Condition Disciplines, Dr. Brown commenced Silent Night Therapy to better help snooze apnea clients. Visit our website at www.sleepbetterny.com and get in touch with 631-983-2463 for an appointment.

    Highlighted Impression Credit score: Bruce Mars on Unsplash.