Sandra Wilkes: Medicaid plays major role in local health care

Published 12:00 am Monday, September 26, 2011

By Sandra Wilkes
Special to the Salisbury Post
Last year Medicaid paid $163,049,159 for health care for almost 24,000 Rowan County residents, representing 17 percent of the countyís population. Breaking those numbers down, Medicaid assisted close to 17,000 parents and children and 7,000 elderly, blind and disabled adults.
With the persistently high unemployment rate, many families have had to turn to Medicaid and other public assistance programs for the first time. A federal-state health insurance program that was signed into law in 1965 by President Johnson, Medicaid has become over the years the largest publicly funded insurance program in the nation. As an entitlement program, the government must pay for covered health services of eligible Medicaid beneficiaries. Without this coverage, our most vulnerable citizens may not have medical exams and preventive check-ups, nursing home care, prescription drugs, physical therapy, mental health services and pre-natal care.
Both the number of Medicaid recipients and the cost to provide their care will increase significantly in the next two to three years, when health-care reform expands the current Medicaid coverage groups to include adults who are not responsible for minor children and who are not disabled, blind, or elderly, and whose annual gross income does not exceed 133 percent of the federal poverty level. It is expected that many low-income adults will take advantage of Medicaid when this expansion goes into effect.
Controlling costs
Medicaid cost containment is a pressing concern and has led to several statewide initiatives. Managed care is one state initiative that has very effectively improved the quality, use and cost-effectiveness of care for Medicaid recipients, especially for patients with chronic diseases. Rowanís managed care program is Community Care of Southern Piedmont. CCSP funds a Social Services-managed care coordinator, who works to get Medicaid recipients assigned to a primary care physician. Over 20,000 of Rowanís recipients are assigned to a primary care physician. Having a primary physician and a patient-centered medical home means the patient gets comprehensive routine and preventive care, costly medical emergencies are fewer, and the potential is reduced for recipients to go from doctor to doctor without anyone overseeing their care.
Many Medicaid-covered children also benefit from Social Services child support services. Child support agents strive to ensure that court orders for child support include medical support for the child when the non-custodial parent can provide that coverage through his or her employer. Out of 664 child support orders established last year, 637 obligated the non-custodial parent to provide medical insurance. Last year, the Medicaid cost avoidance because of medical child support orders was $281,079. Non-Medicaid insurance policies are tapped first, before Medicaid.
The N.C. Division of Health and Human Services/Division of Medical Assistance includes a Third Party Recovery Section whose staff are responsible for reviewing paid Medicaid claims and determining if a third party insurance should have paid the claims instead, particularly in claims related to auto accidents. Last year, $16.7 million was recovered and returned to the Medicaid program as a result of this process.
Crack down on abuse
Another cost containment measure is to crack down on Medicaid fraud and abuse by the consumer and by the medical provider. An example of provider abuse is when the provider bills for services that were either not rendered or not medically necessary. To report provider fraud and abuse, contact the Division of Health and Human Services Customer Service Center at 1-800-662-7030. The division works closely with the attorney generalís office in investigating and prosecuting abusers. Last year, the attorney generalís office recovered more than $53 million in Medicaid payments that were made fraudulently.
Consumer abuse occurs when the Medicaid recipient fails to accurately report his financial situation or that he is covered by other medical insurance. It also occurs when another person uses a recipientís Medicaid card. To report consumer abuse, call the DSS Fraud Investigator at 704-216-8414, or call DHHS.
Looking for cuts
Governor Purdueís budget mandates that millions of dollars must be cut from the stateís share of Medicaid spending. As a result, DHHS will continue to look for and implement cost saving measures, including cuts to Medicaid covered services or cuts in the rates paid to medical providers. DHHS will be hard-pressed in deciding where to make cuts that will be the least harmful to those in need.
Having health insurance is obviously beneficial to oneís physical health. Medicaid recipients are less likely to suffer pain, to lose teeth, to be without life-saving medications, or to be incapacitated with chronic illness. Knowing that coverage is there when needed is a boost to the general well being of many low-income Americans. Their stress level is lower when they do not worry about paying for their childrenís doctor bills or keeping a beloved parent in a nursing home.
Those interested in applying for Medicaid should come by the Department of Social Services office at 1813 E. Innes St. in Salisbury to see a caseworker or to pick up a mail-in application. Office hours are 7:30 a.m. until 5 p.m., Monday through Friday. For more information, call the office at 704-216-8330 and ask to speak to a Medicaid representative.

Sandra Wilkes is director of the Rowan County Department of Social Services.

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