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Contributor: North Carolinians Worked Together to Enact Medicaid Expansion. Our Collaboration Can’t End Now.


The sustained, collaborative effort to expand Medicaid will improve the lives of working North Carolinians who, prior to enactment, earned too much to qualify for Medicaid, but not enough to afford insurance on the marketplace.

December 1, 2023, marked a momentous occasion for North Carolina: That’s the day eligibility for our state’s Medicaid program expanded. It’s been nearly 10 years since the Affordable Care Act went into effect. Since that time, debate and discussion around Medicaid expansion have been guided by the mountain of evidence demonstrating how access to high-quality health care is vital to individual well-being and for the long-term health of communities.

Medicaid expansion is happening because lots of folks worked together across the state to understand the challenges North Carolinians face and the opportunities Medicaid expansion would deliver. Communication through this process has been critical. It’s taken time for the people of our state to learn more about Medicaid and its impact on health care. Leaders have been talking about how important health care is to North Carolina’s long-term strength, and the value of that dialogue can’t be overestimated.

Transforming how Medicaid works in North Carolina has been a journey. As North Carolina’s only not-for-profit insurance company—driven solely by our purpose to improve the health and well-being of our customers and communities—Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is proud to be engaged in this process through our Healthy Blue Medicaid managed care plan.

This sustained, collaborative effort is going to improve the lives of a lot of working North Carolinians who, prior to enactment, earned too much to qualify for Medicaid, but not enough to afford insurance on the Marketplace.

Medicaid expansion in North Carolina will increase the eligible population to include adults aged 19 to 64 years who have incomes up to 138% of the federal poverty level. For example, expansion gives health care coverage to single individuals making under about $20,000 a year. Likewise, a family of 3 earning under about $34,000 combined will now be eligible.

Best estimates suggest that expansion will make nearly 600,000 North Carolinians newly eligible for health care benefits under Medicaid by the end of the second year. This includes:

  • Around 260,000 currently receiving benefits under Medicaid Family Planning (a program that provides limited Medicaid benefits) who will automatically be enrolled in full Medicaid health care coverage
  • 100,000 beneficiaries who may have lost full Medicaid coverage during recertification in the absence of expansion
  • 200,000 people not currently enrolled in Medicaid statewide who are expected to enroll in the first 2 years

Medicaid expansion doesn’t just improve access to care for those individuals who directly receive benefits. It’s also going to strengthen the hospitals that all North Carolinians need.

Alongside Medicaid expansion, the NC General Assembly created the Healthcare Access and Stabilization Program (HASP). This will increase Medicaid reimbursement to acute care hospitals and critical access hospitals up to levels closer to commercial payment rates. HASP payments will be financed through quarterly assessments of hospitals and federal funds.

According to the NC Healthcare Association, North Carolina hospitals and health systems will receive up to $1.8 billion in federal dollars to improve access to care for Medicaid patients through HASP. These payments will help hospitals across the state expand their capacity to serve additional Medicaid members.

By strengthening hospitals, most notably in rural areas, it will help more North Carolinians access health care, especially preventive care. An expanded statewide focus on preventive care will keep our communities healthier, provide stability, and reduce health care costs overall.

The Business Community's Support of Medicaid Expansion

Over the years, business leaders have been increasingly vocal in our statewide debate. That dialogue has raised more awareness of how the workers affected by these changes are vital to our state’s economy and well-being.

For example, it’s estimated that 57,000 food preparation and service employees will benefit when Medicaid expansion closes the coverage gap; 44,000 construction workers and 38,000 cleaning and maintenance workers will benefit. The list goes on: farmers, transportation workers, office and administrative support. There are even an estimated 16,000 health professionals—such as dental assistants and nurses—who will now get coverage.

It’s in everyone’s best interest to keep these employees and their families healthy and able to participate in the workforce. That’s why a broad coalition worked together to make expansion possible…and to make implementation successful.

The impact of expansion on the health of workforce-eligible residents will be considerable. Think for a moment about what a Medicaid managed care ID card brings for the member who receives it.

These individuals and their families get much more than better access to routine physicals and emergency care. They also get extra support for the whole person…the whole family. They have access to an array of resources that promote health and well-being at the household level.

  • Individuals will have better access to treatment for chronic conditions like diabetes and heart disease. Taking a preventive approach to these conditions will keep potential trouble-spots from escalating to the point of crisis, which hurts families, undermines the workforce, and puts an undue strain on our health care system.
  • They’ll have better access to mental health care. Anyone with unmet mental health needs can find it more difficult to adhere to their prescriptions, lead physically active lives, or get regular sleep, and they are more prone to self-medicate to address feelings of anxiety or depression. All of this can undermine any employee’s productivity.
  • Through value-added services, Medicaid plans can provide whole-person support, helping improve access to resources to address non-medical drivers of health. At Healthy Blue—Blue Cross NC’s Medicaid program—we offer a full range of value-added services to eligible members, from 3 months of fresh fruits and vegetables for members diagnosed with obesity or diabetes, to allowances for home repairs, such as ramp installations and mold removal, to Uber gift cards to improve access to grocery stores and community events.

Younger members of the family can benefit, too. Healthy Blue offers members value-added services that will put children on the path to long-term success, including assistance with school supplies, puzzles designed to build STEM (science, technology, engineering and math) skills, tutorial services, and more. Everyone recognizes the importance of getting more students into STEM fields so our state can build the workforce of the future. Sparking a child’s curiosity in STEM is more likely to lead to lifelong interest in these fields. Giving them academic support to ensure classroom success will build more robust skills. That’s exactly what North Carolina needs to keep our economy humming and on the cutting edge.

Medicaid Expansion Is Good for Mothers and Families

Medicaid expansion is good for the long-term health of our state for another important reason: It’s a critical development in our state’s ongoing work to improve maternal health and reduce maternal mortality rates. Stronger, healthier families are the building blocks of stronger, healthier communities.

As it stands, our state currently ranks 29th out of 50 states in maternal mortality. Medicaid expansion will give more North Carolinians access to quality maternity and postpartum care. That alone is significant.

Recent history suggests that this step forward is part of a longer trend toward addressing the significant gaps in our state’s maternal health. When the NC General Assembly authorized the implementation of Medicaid managed care in 2015, expecting parents enrolled in Medicaid suddenly had access to coordinated, whole-person care. In 2022, forward progress continued when new legislation extended Medicaid coverage from 60 days after delivery to 12 months. Now, Medicaid expansion will extend full Medicaid coverage to people enrolled in NC Medicaid Family Planning Program (“Be Smart”).

It's also worth noting that North Carolina is also looking at innovative ways to support expecting individuals and families, by increasing access to doulas and home visits, for example.

At Blue Cross NC, we are really working to take a true population health approach when it comes to improving maternal morbidity and mortality. Data from the Blue Cross Blue Shield Association show that maternal health disparities exist regardless of insurance coverage type. Everyone deserves access to safe and high-quality health care and wrap-around community supports. We anticipate many individuals of reproductive age currently covered through the commercial marketplace will become eligible for Medicaid, hopefully making quality health care more affordable and accessible.

Fulfilling that promise demands an entire system coordinated to care for all patients, which requires ongoing dialogue with providers to understand how they serve their patient populations and what can be done to further lower barriers to care and other resources at the community level.

Education Is the Most Critical Next Step

The go-live date for Medicaid expansion is certainly a crucial milestone, but this journey isn’t complete yet. North Carolinians are now focused on making implementation successful. Success will require partnerships with the state, community-based organizations, county leadership, North Carolina Department of Health and Human Services (NCDHHS), across payers, and more. Through this long process, we’re finding new ways to collaborate.

It’s truly been inspiring to see the state rallying around the work ahead.

If you’re in North Carolina and reading this article, you have a role to play too. The most urgent next step is raising awareness among the people and households who stand to benefit from Medicaid expansion, and all of us can contribute to engagement efforts focused on education and guidance.

Here is some vital information all of us need to be distributing:

  • There is no open enrollment period for Medicaid beneficiaries in North Carolina. Potential enrollees can apply for Medicaid at any time during the year. After a year, if they are still eligible, beneficiaries can renew their plan on the anniversary of their enrollment.
  • There are several routes to enrollment:
    • Online through ePASS, a secure, self-service website at ePASS.nc.gov
    • In person or by phone through their local Division of Social Services (DSS) office
    • By mailing a paper application available at ncgov.servicenowservices.com
    • It may take up to 45 days for the applicant to find out if they are eligible for Medicaid.
  • NCDHHS leadership has really done excellent work rolling out this process and helping North Carolinians get the information they need.
    • For applicants and providers alike, the NCDHHS website is the go-to resource for enrollment information, research, FAQs, and more.
    • Most people are perplexed by insurance. Any member or potential Medicaid member who needs help understanding the terms should turn to the MAXIMUS enrollment broker that NCDHHS has set in place.This resource can help members determine if they are eligible for Medicaid. MAXIMUS can help them understand fundamental terms and benefits, and also help them choose a health plan. MAXIMUS can be reached at www.nchealthplans.gov.

Providing more North Carolinians with access to affordable, high-quality health care is the right thing to do for our state and for the health of our communities, and we can’t improve access without raising awareness of the opportunities that are out there. Engagement efforts need to unfold across multiple channels to ensure they land where they need to.

From the Blue Cross NC perspective, people with questions about Medicaid can always reach out to Healthy Blue via our website or find us at one of the many community events we’ll be hosting throughout the year. Blue Cross NC agents, customer service representatives, and Healthy Blue staff are available to support. But we aren’t content sitting back and waiting for people to come to us—we want to meet them where they are.

That’s why we are working with our connections in the communities we serve, partners, and on-the-ground resources in every county to help North Carolinians navigate the processes of Medicaid expansion. Our Healthy Blue Medicaid plan, in particular, is leveraging our strong relationships with providers, community-based organizations, and members to spread the news about expansion and educate about how the process works.

We have a robust community engagement team, which is playing a big part in our strategy. They’re on the ground, covering every region in the state. New members, providers, and community-based organizations can all turn to them for information and help. That personal connection and on-the-ground support will be critical once enrollment opens. Our Blue Cross Centers in Charlotte, Raleigh, and Boone are also great points of contact. We’re reimagining these spaces, not strictly as brick-and-mortar outlets to sell products, but as information hubs and community resource centers, and we hope to be bringing additional centers to towns across the state.

Through all these and other resources, we’re pursuing a multidimensional education strategy that includes training sessions, social media, community events, and other activities to share tools and information.

Blue Cross NC is proud to be North Carolina’s hometown insurer. We’ve been woven into the fabric of our state for 90 years now, without interruption. Helping individuals and families get enrolled in Medicaid is just one of many reasons why we continue to explore new ways to connect with North Carolinians in the communities where they live.

Working Together Toward Success

Blue Cross NC is working to make health care better for all North Carolinians. We won’t stop until health care is better for all. Increasing access to care is integral to that commitment.

That’s why we couldn’t be more excited about the arrival of Medicaid expansion in our state. We welcome this opportunity to collaborate with so many others across the state to make Medicaid expansion a success. Together, we’ll be creating healthier families, healthier communities, and a healthier North Carolina.

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