31 Tiers to the Medicaid Waiver: Research Indicating Such Strategies Result in Adverse Health Care Access for Low-Income Recipients

An 'original article' in the latest NCMJ, North Carolina Medical Journal, entitled, "State Medicaid Policies and the Health Care Access of Low-Income Children with Special Health Care Needs Living in the American South" concludes that "Policymakers interested in addressing state budget gaps should be concerned that doing so by increasing the frequency of Medicaid eligibility renewals or by cutting health care provider reimbursement rates may well result in adverse health care access for low-income Southern Children with special health care needs."

Here is the link: http://www.ncmedicaljournal.com/wp-content/uploads/2012/01/73102-web.pdf

This piece of research was only associated with the demanded Medicaid renewal every six months.  Contrarily, Medicaid monies for outpatient mental health treatment under the Medicaid waiver has significantly shorter periods associated with renewal.  This means more frequent paperwork for providers.  And that means providers drop out and stop providing Medicaid services.

The purpose of the Medicaid Waiver, currently in effect under Western Highlands Network LME, is to keep a tight reign on the money being spent by creating a mountain of paperwork in the form of eligibility renewals.

As you might imagine, any provider who can opt out of this, is doing so.

Wrapping around to that matter, the latest NC Disability Rights 'On Target' newsletter gave us this Legal Update associated with the Medicaid Waiver as associated with a lawsuit which they pressed
to halt reductions to home community based services as per PBH, Piedmont Behavioral Health (the LME which launched the Medicaid waiver upon Western Highlands Network LME) :

"Legal Update

Judge orders restoration of services and certifies class action in K.C. v. Cansler and PBH, 11-CV-0354-FL (EDNC).

            On March 29, US District Court Judge Louise Flanagan ordered the State of North Carolina to halt reductions to home and community-based services and restore lost services until the state Medicaid agency and its managed care contractor, PBH (formerly Piedmont Behavioral Healthcare), comply with legal requirements for providing Medicaid beneficiaries with adequate notices and opportunities for impartial hearings when their services are denied, reduced or terminated. The Court noted that without an injunction, the plaintiffs – children and adults with disabilities – would experience deteriorating health, financial strains and the threat of having to go into institutions to receive care.

            This lawsuit was filed by Disability Rights NC and co-counsel, Legal Services of Southern Piedmont and the National Health Law Program, in 2011 to challenge the manner in which DHHS, acting through its contractor PBH, had implemented a new version of a Medicaid waiver program known as the Innovations Waiver. PBH, a managed care organization within the LME system, made substantial changes to the Innovations Waiver serving those with Intellectual and Developmental Disabilities. The changes included the implementation of as many as 31 tiers within the waiver, each with its own budgetary limit. The tier assignment process, which resulted in substantial service cuts for a number of waiver recipients, was conducted without benefit of any appeal or due process procedure that would allow the recipient to challenge the tier assignment.

            Judge Flanagan also certified the case to proceed as a class action. Disability Rights NC is working on obtaining a list of all class members and will send a notice to the class."

Two Different United Health Care Clients, for Same CPT Code, Paid at Vastly Different Rates

There are two clients of mine who both have United Health Care (POB 1459 Route MN 010-S155 Minneapolis, MN 55440-1459).  For one of them, for the Health & Behavior CPT Code 96152, I am paid appropriately.  For the other client, same code, I am paid nothing.  The invoice information comes on the same piece of paper indicating such.

The 'excuse' for the non-paid one is stated to be a problem/ error code with the client having been "self directed out of network" which makes no sense as this company defines itself as being a Medicare advantage company (pretend Medicare, with 3x the administrative costs, which the tax payers are picking up less and less).

As I stated in an earlier post, I have been advised by my biller to contact the NC Insurance Commissioner. I am waiting to see if this company can clear this up prior to doing this.

After I waited on the phone over an hour about a week ago, trying to get this resolved, I was informed that my biller needed to bill on the 'behavioral health' side of things rather than 'the medical side' of things (whatever this means...I have no idea and they could not tell me....the Health & Behavior codes, series 96152, are billed at the medical rate of 80%----if that is what they mean----rather than the completely unjustified mental health rate of 50%).  But then that is not always so as associated with outpatient mental health care as evidenced by TRICARE's billing structure.

You'd have to have a library to keep up with all of this.

Please, someone: give us a universal provider so we don't spend time on this.