Annual Report 2022

---

Dear Reader,

2022 was a busy year for the NC Medicaid Ombudsman. While we learned a lot in the first year of Medicaid Transformation, the second revealed unique challenges and surprises.

The NC Medicaid Ombudsman began its effort to support Medicaid beneficiaries in their transition to NC Medicaid Managed Care. What we found were several opportunities to help that we hadn’t expected. We supported beneficiaries with navigating challenges like data issues, insufficiencies with prior approval documentation, and provider network adequacy concerns, including limited capacity of some health plans to provide reasonable access to in-network primary care and specialty providers. We are proud that we could assist beneficiaries in navigating these issues. We shared our findings with NC Medicaid so they may use our experiences to improve processes where needed.

Next year will be an equally busy time for the NC Medicaid Ombudsman. Tailored Care Management launched Dec. 1, 2022, but Tailored Plans are delayed. We will continue to be on our toes, as we navigate this new environment in 2023 and beyond.

Keep scrolling to see the difference we’ve made. Thank you for your support.

Angeleigh Dorsey
Director, NC Medicaid Ombudsman

Listening to beneficiaries

We answered 18,023 calls.

Julio* received two Medicaid identification cards from his health plan with different member numbers on them for his infant son. Because the health plan also recorded the baby’s birth date incorrectly, the pediatrician could not treat the child since, in the eyes of the health plan, he’d not yet been born. Julio turned to the NC Medicaid Ombudsman for assistance in Spanish. We were able to work with several different entities to navigate this complex data problem. Once we resolved the issue, we were able to communicate with the pediatrician, so Julio can again access the care he needs to keep his son healthy.

*Names and some minor details have been changed to protect the confidentiality of those we serve.

---

Following through

We opened 14,038 cases (up from 6,714 in 2021), resolving 98% of them.

Keisha* is on a fixed income and her prescriptions were more than she could afford. Her pharmacy wouldn’t accept vouchers and was unwilling to transfer her prescriptions to one that would. With one insulin injection left, she called the NC Medicaid Ombudsman in a panic. By escalating her case, we were able to get her insulin refilled for the next month. However, we knew this would be a recurring challenge. The Ombudsman helped Keisha request a care manager through her health plan who has been incredibly supportive and useful in getting her prescriptions covered. Through the Healthy Opportunities Pilot Program, Keisha also now receives a food box once a week, significantly improving her health.

*Names and some minor details have been changed to protect the confidentiality of those we serve.

---

Providing support and referrals

When beneficiaries needed more help, we connected them to our partners to get information and resources.

Amanda* is a young mother with a small child, managing a full-time class load at a community college. In researching her health plan she learned that birth control is a covered benefit, so she set out to get a prescription for birth control pills. When her claim was denied, she reached out to the NC Medicaid Ombudsman for help. 

First, her health plan said she didn’t qualify for birth control because she was already pregnant, which was not true. They then told Amanda that the problem was with her pharmacy, so she went to a different one; again it was denied. Next they requested that her primary care provider change her prescription to a preferred medication, the prior authorization for which was also denied.

Because Amanda did not receive a “denial of care” letter in writing, she did not receive “due process of an adverse benefit determination.” The Ombudsman escalated this case to NC DHHS and referred it to a legal partner agency. One week later, the health plan authorized the prescription. Now Amanda can focus on her education and grow her family when she’s ready.

*Names and some minor details have been changed to protect the confidentiality of those we serve.

---

Identifying systemic issues

We highlighted challenges to NC DHHS and facilitated solutions.

Burton* was diagnosed with stenosis of the neck that was so severe he required surgery. When Burton’s primary care provider prescribed acupuncture to help with pain management, he purposely changed plans to one that covered the service. He tried to go to three different acupuncturists, but each said his new health plan would not cover the cost, asking him to prepay. When contacted, the health plan referred him to an in-network provider 200 miles away! Burton called the NC Medicaid Ombudsman who discovered that he was improperly assigned to a plan in a different state. The Ombudsman escalated the problem, and identified that this issue had happened to other beneficiaries across North Carolina. Today, these problems have been solved and pain eased.

*Names and some minor details have been changed to protect the confidentiality of those we serve.

---

Reaching out

As COVID rates decreased, our teams safely networked with our communities.

---

Partner with us!

The NC Medicaid Ombudsman is always looking for community partners to help educate and empower NC Medicaid Managed Care beneficiaries.