NCMS Summarizes Medicaid Reform Draft Waiver

To highlight the important points contained in the state’s draft Medicaid reform waiver application presented last week by the NC Department of Health and Human Services (DHHS) to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice, North Carolina Medical Society (NCMS) staff has thoroughly reviewed the document and written this summary. The draft application must be approved by the Centers for Medicare and Medicaid Services (CMS) in order to implement the Medicaid reforms adopted by the NC General Assembly last fall.

The DHHS has stated repeatedly they are seeking meaningful input on the waiver application from the health care community and have scheduled ‘listening sessions’ throughout the state in March and April. See when officials will be in your area here. Watch the NCMS Bulletin for more information on these sessions and how you can most effectively participate. The waiver application is due to CMS by June 1.

The NCMS is committed to continuing our ongoing, constructive dialogue with DHHS on Medicaid reform to help ensure our priorities are met as the reforms are implemented. Physician leadership remains a key NCMS priority. NCMS staff and our Medicaid Reform Task Force are fully engaged in communicating our priorities to DHHS including the ideal leadership role of physicians in the managed care organizations that will be statewide Medicaid providers under the proposed reform plan. We are taking a constructive approach to answering this challenging question, and look forward to a successful implementation process.

The NCMS wants to hear your feedback. Your input is valuable and will assist us in advocating for changes to the draft waiver to improve the final product which will ultimately be submitted to the CMS for approval. Please share your comments at

Visit NC DHHS’ Medicaid reform website for more on the state’s plans.

Read the full draft waiver application.

NCMS draft waiver summary.


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  • Kerry Willis

    The fact that DHHS staff admits they have no projections or studies to judge the impacts on small and rural practices should alarm us all. The current draft lacks sufficient detail for anyone to evaluate those risks or benefits if any. This proposal would more likely increase costs and lower access and lower the quality of care than improve it. I see no reason to support this proposal.
    Never mind that the Medicaid budget will come in under targets for a second straight year in a row. How many other large budget items will be under the allotted spending targets. The legislature spent $500,000 on an audit that told them our current Medicaid program was financially a great deal and very well run. Perhaps they should spend some money comparing this draft to the current program and see what the possible chance they achieve any of the goals mights be…….

  • Dave Tayloe, Jr., MD

    Medicaid Reform Comments
    1. Multiple Prepaid Health Plans (PHP’s) will operate in each region. This will make it very difficult to maintain the integrity of the medical home that we have developed within Community Care of NC. At the current time, physicians deal with one payer and one care coordination group, making it possible to develop a comprehensive local system of care that is good for patients, families, and providers. So, even though we are paid only 77% of the Medicare rate for our most common office visit, we can cut costs by not having to pay staff to deal with multiple payers and multiple care coordination agencies. It would make more sense to assign one payer to each region and reward the most efficient payers with more business going forward and by terminating the less efficient payers. If multiple payers are assigned to a region, large practices will educate their patients to only sign up for one plan; that one plan will be the plan of choice of the practice; the large practices will refuse to participate in the other plans. So, if the state wants competition, the state needs to assign specific plans/payers to specific regions.
    2. We have a maldistribution of primary care providers. This could be alleviated if the state would divide the state into academic center-based regions and fund the academic centers and require those academic centers to use those funds to make sure there is a certain level of primary care (patients per primary care provider) in every county. This is already going on in the east, thanks to the vision and energy of East Carolina University/Brody School of Medicine/Vidant Medical Center.
    3. If we want child-bearing women to be as healthy as possible, they will need access to health services throughout their child-bearing years. It makes no sense to offer them Medicaid benefits when they become pregnant and then to terminate their Medicaid six weeks after they deliver. If we are going to insure the parents of foster children, we should expand Medicaid to cover child-bearing women throughout their child-bearing years. We need for child-bearing women to be healthy if we expect our babies to be healthy. At this time, I would guess that well over half our child-bearing women are obese, about one-third smoke tobacco, and about one-fourth use substances like marijuana, narcotics, and alcohol. These conditions put mothers at risk to have babies with serious problems. Over half the women who deliver at our hospital are eligible for Medicaid.
    4. Payment of providers who provide care for the Medicaid population should be equal to that of providers who provide care for the Medicare population. This needs to be clearly stated in the waiver proposal.
    5. We already have the Person-Centered Health Communities (PCHC’s) that are described in the waiver proposal. The only thing new about the proposal is the payment scheme. It would make more sense to abandon the waiver idea and move to capitation within the current Community Care of NC framework. There really is no cost crisis within NC Medicaid, and this waiver proposal will put things in limbo for the next 3-5 years with no guarantee that we will have a better system; in fact, I can guarantee you that if we go to multiple payers per region in Medicaid, access to care and quality of care will plummet.

    Dave Tayloe, Jr., MD,FAAP
    March 6, 2016

  • Don Bias

    This is too complicated. It is not something any physician wants to participate in. You will not have enough physicians to participate. There will be more ER visits than ever. There will be no way this will be seamless. There will be no advantage and no reliable fee schedule. Data collection will be inaccurate, and will hamper P4P.We can never rely on any government medical plan that will help us or make our lives easier. I am in a small independent practice, I do not want to participate in any larger group, but will not be able to survive these regulations and data collection. I will not have the time or money to accomplish what is expected.