Nonprofit ups income eligibility for healthcare access ahead of Medicaid expansion

Original article posted on Port City Daily by Amy Passaretti Willis.

On Dec. 1, Medicaid expansion in North Carolina will take effect, offering health insurance to more individuals; however, there are still more than 600,000 statewide who will not qualify. As a result, a local nonprofit serving the under- and uninsured will increase access to its services to bridge the gap.

According to Cape Fear Healthnet executive director Leslie Smiley, 60% to 75% of current Cape Fear Healthnet patients will meet the new Medicaid guidelines, opening up space in its program to serve more people.

Medicaid expansion increases the eligible population to adults aged 19 to 64 who have incomes up to 138% of the federal poverty level. It will provide health care coverage to single individuals making $20,000 a year or less. Likewise, a family of three earning under $34,300 combined will now be eligible for Medicaid.

In New Hanover County that equals about 17,000 people, New Hanover County social services director Tonya Jackson told Port City Daily this summer. Based on the 2020 U.S. Census, 22,000 adults in Cape Fear Healthnet’s service area — Brunswick, New Hanover, Pender and Columbus counties — were considered low-income and uninsured.

This means Cape Fear Healthnet could essentially serve an additional 5,000 people who are uninsured but will not qualify for Medicaid.

To assist with access to healthcare, on Oct. 1 Cape Fear Healthnet raised its income limits for eligible individuals from 200% of the federal poverty level to 300%. A single person who makes $43,000 a year qualifies.

In New Hanover County, which makes up 55% of Cape Fear Healthnet’s customer base, there are roughly 97,255 people who earn 300% of the federal poverty line, according to the U.S. Census Bureau.

Cape Fear Healthnet has already seen an increase in patients since April, following the end of the federal state of emergency enacted as a result of the Covid-19 pandemic. It required states to keep individuals enrolled in Medicaid, even if they no longer qualified.

This has led to what Smiley called the “unwinding of Medicaid.”

On June 30, the first wave of individuals who had been receiving Medicaid but were no longer eligible, officially lost coverage. Since, Cape Fear Healthnet’s numbers have slowly been rising.

The nonprofit’s move to increase eligibility requirements to serve individuals earning up to 300% of the federal poverty level will mostly impact those on the cusp, or right over the 200% guideline, Smiley said.

She plans on reaching out to individuals who were just over the 200% limit when applying in the past but were denied, to see if they’re now eligible for Cape Fear Healthnet’s services.

“We know there are way more people out there who meet the criteria and either aren’t aware of our program or have not been able to get access,” Smiley said. “We know we’re not reaching everyone that could benefit.”

Low-cost to free healthcare

Established in 2008, Cape Fear Healthnet works as an umbrella organization for a network of five primary care clinics and more than 50 specialty care providers who offer healthcare to individuals who can’t afford insurance in the private sector and don’t qualify for Medicare or Medicaid. Included are Cape Fear Clinic, Coastal Horizons Health, MedNorth, Pender’s Black River Family Medicine or Brunswick’s New Hope Clinic.

Currently, these organizations serve 2,200 people annually through the Cape Fear Healthnet program.

Eligible patients choose one of five partner clinics to receive either free care or charge a minimal copay, around $3 or $4. MedNorth and Black River work on a sliding scale based on income. All except New Hope accept Medicaid patients as well, meaning those who are now eligible can remain with their current providers.

“But if an individual can’t afford to pay it, they are seen anyway,” Smiley said.

Cape Fear Healthnet is funded almost solely through roughly $600,000 annually in grants and foundations including United Way, Duke Endowment, Cape Fear Memorial Foundation, the Landfall Foundation, New Hanover County’s non-county agency funding, Brunswick County’ Office of Rural Health, Novant Health and the Leon Levine Foundation. Last year, it also was awarded $30,000 from the New Hanover Community Endowment and has applied again in 2023.

In 2022-2023 it offered the equivalent of $28.4 million in medical care to patients.

Cape Fear Healthnet’s community value is evident in its specialty care program, overseen by medical director Andre Leonard.

Providers donate their services for Cape Fear Healthnet patients to receive orthopedic and heart specialty care and cancer treatment, as well as health assessments in neurology, dermatology, and other fields.

“A lot of folks can go to clinics and get connected but cannot get specialty care or care management without being eligible for our program,” Smiley said. “That’s the big draw for us. All things can be addressed if we can get them connected through our program.”

In 2021-2022, Cape Fear Healthnet helped connect patients to 4,300 specialty care visits, a value of $981,795.

Along with upping its income eligibility, the nonprofit enacted additional initiatives to further reduce barriers to healthcare. It no longer has an asset limit — meaning a checking or savings account with more than $6,000 — allows phone interviews to combat transportation issues and co-located some specialty care providers for easier access.

Individuals eligible for Cape Fear Healthnet are also automatically enrolled in Novant’s charity care program, so any hospital services needed do not require a second application process.

The nonprofit has partnerships as well with Community Care of the Lower Cape Fear with the Healthy Opportunities Pilot program, which refers patients to additional services around social determinants for healthcare. Barriers such as housing, transportation and finances can further reduce access to medical services and the HOP program works to mitigate those challenges by referring patients to appropriate resources.

“The healthcare system can be overwhelming and confusing,” Smiley said. “We can connect them to an RN, LPN or community health workers to help with whatever the need may be.”

Though 600,000 North Carolinians will now be insured with Medicaid, there will still be 700,000 uninsured. In Cape Fear Healthnet’s service area, 25,000 residents ar uninsured and live below the 300% federal poverty level.

“Everyone’s talking like the expansion will fix all the problems,” Cape Fear Healthnet board chair John Devaney said, adding the process will not necessarily be a smooth rollout.

Smiley said Cape Fear Healthnet will ensure individuals are eligible for its program to begin accessing primary care services while their Medicaid applications are under review. The process can be extensive and she wants to be sure people can receive healthcare in the interim.

Once they are accepted by Medicaid, patients can stay with their established provider, since all four of the five clinics — the exception is New Hope — that partner with the nonprofit accept Medicaid patients as well.

“We’re hoping it’s a real opportunity for the word to spread to folks that didn’t know we existed,” Smiley said. “You may not get Medicaid, but you can get primary care, prescriptions, and specialty care.”

Cape Fear Clinic expects increase in uninsured 

Cape Fear Healthnet currently operates in a temporary location on Cape Fear Clinic’s campus, aiding in the two entities’ collaboration.

CEO of Cape Fear Clinic — one of the five participating providers in Cape Fear Healthnet — and Cape Fear Healthnet board chair John Devaney touted Cape Fear Healthnet’s services as extremely beneficial to the healthcare community.

“Our goal is to make sure everyone gets what they need,” Devaney said. “We’re not in competition.”

Without Cape Fear Healthnet offering its services, Devaney said he’d have to hire two full-time employees to screen patients for eligibility.

Cape Fear Healthnet acts as a hub to disperse the responsibility of charity care across its multiple providers. It doesn’t put the resource burden on one entity.

“Going through a centralized location ensures there’s equity for the patient population that needs that care,” Devaney said.

Cape Fear Clinic followed in Cape Fear Healthnet’s footsteps by increasing its qualified charity care to 300% of the federal poverty level earlier in the fall. Devaney said he does not expect a huge increase in patients at the top end of eligibility since the majority he serves make less than 140%.

“The main problem we have is when there’s someone right on the line,” he said. “For years we’ve been at 200%, so when somebody comes in and they make 210% or 212% — in real life it’s not a lot of difference in terms of money or resources they can muster to take care of their health care needs.”

He said the increase will offer care to those individuals not being served by anyone in the community.  Smiley noted the increased cost of living overall has made it even more difficult for individuals to afford a quality insurance plan.

“The hope is we will capture those people that have not been captured by anyone in the community,” Devaney said. “Honestly, it was just leaving people with the emergency room — not a great option for primary care.”

Conservatively speaking, if the patients who received low-to-free care at Cape Fear Clinic last year went to the emergency room instead, it would equal roughly $18 million, Devaney said.

Cape Fear Clinic was founded in 1991 through collaborative efforts of three physicians and members of St. Mary Catholic Church who realized many low-income individuals had little or no access to medical care for chronic conditions. When it first launched, the clinic served 20 patients a week on a first-come, first-serve basis. Now its database has close to 1,300 patients, which fluctuates daily.

Last year, Cape Fear Clinic fulfilled 6,000 appointments, averaging four to five per person, across all services including medical care, behavioral health and pharmaceutical.

About 20%, or 150 to 200 of Cape Fear Clinic’s current population, are enrolled in Medicaid. After the Dec. 1 transition to Medicaid expansion, Devaney anticipates his patient ratios to flip and result in 80% Medicaid and 20% uninsured.

“We do anticipate an increase in the number of uninsured,” he said. “People will try to get Medicaid but 138% of poverty is the cutoff.”

Devaney said he plans to coordinate with the county’s department of social services to make sure the clinic, as well as Cape Fear Healthnet, is listed as a resource

Funded by grants and donations, Cape Fear Clinic anticipates an increase from its current $1.4 million budget following Medicaid expansion. Devaney said there could be 50% more money coming in with expansion of Medicaid-eligible patients.

As a result, he can leverage added dollars to increase the number of uninsured individuals still requiring access to health care. For example, if a service that’s being provided for free now will bring in $100 from Medicaid moving forward, the clinic can use that money to serve more people.

Cape Fear Clinic is staff-run and volunteer supported with 19 paid employees and more than 200 volunteers across the spectrum from doctors, nurses, pharmacists, students, retirees, administrative positions and more.

“We could not do everything we do without our volunteers,” Devaney said. “I don’t envision a time we will not have volunteers, even with the Medicaid expansion.”

Their input equaled that of roughly two full-time positions last year, with more than 4,000 donated hours.

While Cape Fear Clinic is a free, charitable care organization, it does charge a nominal fee for certain prescriptions and services. But same as Cape Fear Healthnet’s policies, if someone cannot afford it, it doesn’t impede him or her from receiving care.

However, Devaney said up to 80% of his patients do contribute in whatever way they can toward healthcare.

“When they feel like they’re contributing, it lands better than giving it away,” he said. “We’ve seen better outcomes in terms of showing up to appointments more regularly and taking medications as prescribed because they’re invested.”