5. Administrative Burden

When determining the withhold percent, NC Medicaid has several payment specificities to consider. Some states have robust methods to these calculations with respect to quality measures. For example:

• Louisiana withholds one percent of each

MCO monthly capitated payment, which can be earned back if the MCO meets the state-established measure or improves two percentage points from the prior year.429 • Missouri and Ohio withhold three percent of each MCO annual capitated payment, which can be earned back if the MCO meets certain standards on HEDIS measures. High-performing MCOs in Ohio are eligible for an annual bonus, which is funded by an unreturned withheld dollars.430

Additional Considerations

NC Medicaid’s plan to consider overall and relative performance improvements in disparate outcomes when it determines rewards for quality metrics is promising. Disaggregating the quality measures (hypertension, tobacco cessation, perinatal depression screening and follow-up, and substance use screening and intervention) specifically for pregnant and postpartum women as separate measures to withhold PHP capitation payments would incentivize PHPs to improve maternal health outcomes but requires a medium-term investment from NC Medicaid. NC Medicaid cannot withhold payments until 2023. Additionally, NC Medicaid would need to analyze the disaggregated data submitted by PHPs in order to confirm that there have been recent and consistent racial and ethnic disparities among these quality metrics.

5. Administrative

Burden

NC Medicaid should reduce administrative burdens that keep pregnant and postpartum enrollees from enrolling in Medicaid.

Implementation: • NC Medicaid should create a shortened Medicaid enrollment form specifically for pregnancy Medicaid. • NC Medicaid should pursue a State Plan Amendment to exempt under 21 pregnant people from income determination for pregnancy Medicaid.

NC Medicaid should improve enrollees access to translation services during perinatal appointments.

Implementation: • NC Medicaid should incentivize PHPs to reduce wait times for translation services during perinatal appointments and increase access to translation services through telehealth.

North Carolina Context

Much of the administrative side of NC Medicaid happens at county health departments, making for unique management challenges in easing administrative burdens for Medicaid enrollees. North Carolinians may apply to Medicaid by phone, paper application, in-person, or online. A simplified web application is available across the state in English and Spanish through ePass offered by NC Medicaid. Administrative burdens present a barrier for potential enrollees to access benefits and care. Data from NC DHHS suggests that some pregnancy Medicaid enrollees do not enroll until relatively late in their pregnancy. In 2019,

56 percent of pregnancy Medicaid enrollees received care during their first trimester, with significant disparities between racial and ethnic groups: when disaggregated by race, 65 percent of non-Hispanic white enrollees received first trimester care, while the rate of first trimester care was 58 percent and 52 percent for nonHispanic Black enrollees and Hispanic enrollees, respectively.431

Looking at the state overall, there is a disconnect between Medicaid enrollees and poverty rates (see Figures 12 and 13). Despite the higher poverty rates in the eastern region of the state, pregnancy Medicaid enrollment is lower than in the west. These data suggest there may be Medicaid-eligible pregnant women in the eastern part of the state that never enroll in coverage. NC Medicaid has made progress on easing administrative burden by starting to reimburse for translation services used by enrollees during appointments. However, language inaccessibility was identified in our stakeholder interviews as a barrier to maternal care. A 2021 study of Spanish-speaking pregnant women in North Carolina found that patients who do not speak English have longer appointment wait times due to the time needed to find a translator.432 In a focus group conducted as part of this study, women reported that care centers did not provide sufficient interpreters and sometimes relied on the enrollee’s family members to interpret during appointments.433

Figure 12. Percentage of Mothers enrolled in Medicaid

Source: Jones-Vessey, Kathleen. 2019. “Trends in Infant Mortality in North Carolina.” NC DHHS.

Easing administrative burden offers a chance to reduce disparities and increase Medicaid enrollment for eligible pregnant people. The White House identified administrative burden as a key priority in increasing equitable outcomes through social safety net programs. Their 2021 report offers an application design framework, which NC Medicaid should consider in streamlining pregnancy Medicaid applications (see Table 3).

By using plain language and clear step-bystep instructions, NC Medicaid can increase pregnancy Medicaid enrollment and reduce geographic, racial, and ethnic disparities. The most recent available data on pregnancy Medicaid enrollment processes shows 25 states use shortened Medicaid enrollment forms.434 Exempting people under 21 from pregnancy Medicaid income determination will further reduce hurdles for accessing coverage. California and New York have enacted this policy in their Medicaid programs through State Plan Amendments.435 Given there are racial age disparities for when pregnant Medicaid enrollees give birth in North Carolina, pursuing this recommendation could reduce racial and ethnic disparities by making it easier for younger enrollees to access pregnancy Medicaid coverage. In 2019, Medicaid enrollees under 18 had 1,484 births, about 2.3 percent of all births covered by Medicaid. For all Black non-Hispanic Medicaid enrollee births, 2.5 percent were to those under 18 and for all Hispanic enrollee births, 3.3 percent were to those under 18.436

Figure 13. Estimated Poverty Rates in North Carolina by Perinatal Care Region

Source: Jones-Vessey, Kathleen. 2019. “Trends in Infant Mortality in North Carolina.” NC DHHS.

Opportunity Area to Improve Equity Known Burden Drivers Potential Solutions

Reducing form complexity and improving comprehensibility • Lengthy forms and instructions driven by legal design requirements. • Questions that cannot be answered based purely on an applicant’s own memory or knowledge about themselves. • Multiple or supplemental forms during a single application experience. • Eligibility requirements that are overly complex and not well known. • Ensure that all instructions and notices are written in plain language and translated into multiple languages. • Adopt principles of human-centered design (e.g., early and routine user interviews and A/B testing to continually refine design and language). • Provide step-by-step examples of process involved in claiming benefits, accessing protections, or navigating a service.

Source: Office of Management and Budget. 2021. “Study to Identify Methods to Assess Equity: Report to the President.” Executive Office of the President of the United States.

Additional Considerations

Pursuing a State Plan Amendment requires legislative action, and therefore it is a mediumterm solution to reduce administrative burden for under 21 enrollees. In comparison, creating a shortened application form and improving translation services act are short-term solutions because both can be implemented without legislative action. To ensure that enrollees have access to timely translation services, NC Medicaid should provide financial rewards to PHPs that achieve shorter wait times for enrollees, though all translation services to continue to be reimbursed at a base level regardless of wait times. NC Medicaid should also work with PHPs to expand access to translation services provided through telehealth during enrollee appointments, particularly in areas with translator shortages or for enrollees who speak less commonly spoken languages. These are relatively short-term solutions, as these changes can be made by altering PHP contracts.