Who qualifies for Medicaid in S.C.?

Different states have different rules to determine Medicaid eligibility, and on that spectrum, South Carolina’s rules are stricter than some.

Single adults without children don’t qualify for Medicaid here, with a few exceptions, including pregnancy, blindness and breast or cervical cancer.

Children under 19 who live in families earning less than 200 percent of the federal poverty level may qualify for a Medicaid card. That income threshold is a moving target based on the size of families. For example, families of four can earn up to $3,925 a month for children to qualify for Medicaid, but families of five can earn up to $4,595 a month.

There is a resource limit of $30,000 per family.

Parents and adult children in those families do not qualify for Medicaid unless they earn much less. The net income threshold for a family of four drops to $961 a month and $1,126 for a family of five for adults to qualify.

Source: S.C. Department of Health and Human Services

There’s one thing that almost all Medicaid patients in South Carolina have in common.

It’s not that they’re lazy, unmotivated to find work, or that they lie about their income to qualify for free health care.

It’s that they’re poor.

But complaints leveled against Medicaid beneficiaries and the system itself aren’t new.

On the 1976 campaign trail, Ronald Reagan made frequent reference to a Chicago “welfare queen” with a Medicaid card, milking the system for benefits she didn’t deserve. Two years ago, Mississippi Gov. Haley Barbour accused Medicaid patients of picking up prescriptions through drugstore drive-thrus in their BMWs. During the 2011 legislative session, S.C. Rep. Kevin Bryant, R-Anderson, called the program a “$100,000 Mercedes” hand-out and said it encouraged a culture of dependency.

A report released by South Carolina’s Department of Health and Human Services this month shows health care providers are not immune from stereotyping their poorest patients, either.

“I got tired of seeing my patients rolling up in nicer cars than I drove … to get their free work done,” said Brice Elvington, the office manager of Florence Pediatric Dentistry, who also compared Medicaid benefits to free fast food in the report.

“Our analogy is when Chick-fil-A has a ‘free chicken sandwich day,’ they have the supplies and resources to give out free chicken sandwiches set aside for that particular day,” he said. “If you don’t show up, you can’t go back a week later and demand your free chicken sandwich because you failed to show up on the correct day.”

Sharp comments like these included in the report are indicative of the frustration some health care providers have with the low-income insurance program and whether it should grow.

Expansion mode

Next year, the country is braced for the largest Medicaid expansion since the entitlement program was established in 1965. The Affordable Care Act will allow states to expand Medicaid eligibility to any resident making up to 138 percent of the federal poverty level, but the South Carolina General Assembly voted this year not to participate, even though the federal government offered to foot 100 percent of the bill through 2017.

“They need to fix the system the way it is now before trying to make it bigger,” Elvington said in a phone interview. “I think a lot of providers are frustrated with the way things are now.”

Medicaid patients once made up more than 40 percent of Florence Pediatric Dentistry’s client list, but the practice no longer accepts Medicaid because those patients frequently missed appointments and because the Medicaid agency reimbursed the office poorly for its services, Elvington said.

Reimbursement rates for Medicaid patients are generally lower than reimbursement rates for patients with private insurance. That means dentists, doctors and hospitals tend to make more money from patients with private insurance plans than those with Medicaid cards.

“We’ve voiced a lot of concerns to the people that handle the dental side of it and they would always say things are getting worked on but they never would so we said we can’t continue,” Elvington said.

Florence Pediatric Dentistry may have dropped out of the Medicaid program, but the number of health care providers registered to participate is growing in South Carolina.

In 2012, 51,166 providers were enrolled to accept Medicaid patients, up from 49,105 in 2011 and 46,502 in 2010, according to the state’s Medicaid agency.

Fraud, frustration

Since July 2012, more than 200 new Medicaid patient fraud cases were reported to the S.C. Attorney General’s office, but data from the S.C. Department of Health and Human Services shows that health care providers are guilty of it, too.

In 2012, the department opened 67 new provider fraud cases. It also keeps a running list of 555 health care providers in South Carolina that are excluded from participating in the Medicaid system mainly because of past fraud cases, but also because of revoked licenses, financial felonies and patient abuse.

“I definitely don’t think fraud is a rampant thing in Medicaid in general. I don’t think it’s become a huge issue where we’re getting an exorbitant amount of cases,” said Michael Collisi, director of HHS’s Pursuits of Excellence team. “It’s a very small portion of the public out there.”

More than 1 million South Carolina residents hold Medicaid cards and more than half of those are children.

Collisi facilitated a series of Medicaid meetings across the state this year, which were intended to help the department identify regulations that make doing business in South Carolina harder.

He said the feedback they collected in the final report was mainly constructive, but there were providers who attended the meetings only to complain.

“There’s always somebody who has angst against the program,” Collisi said.

Twenty-seven people attended the three meetings in Florence, North Charleston and Spartanburg.

Profits, prejudice

Dr. Greg Tarasidis, an ear, nose and throat physician based in Greenwood, who did not attend the Medicaid meetings, said that doctors are rightly critical of the Medicaid system, but that doesn’t mean they are prejudiced against poor patients.

“On a frustrated day, you may get that perception. That’s not what any of us want to be focused on, by any means,” said Tarasidis, who represents South Carolina for the American Medical Association.

“Doctors are obviously professional. We take care of people no matter what, for the most part. Unfortunately, medicine has become … more than just that. We still have four walls and roof and bills to pay just like any other small business, so it becomes a business.”

Tarasidis said these concerns are widespread among providers, and more doctors will likely drop out if the Medicaid system doesn’t improve.

But anxiety about profit margins doesn’t fully explain why Medicaid patients are treated differently than others, said Maya Rockeymoore, president of Global Policy Solutions, a national health care consulting firm.

“There are studies that show — and it tends to break down by class and race — people of color and low income get worse treatment in the health care system,” Rockeymoore said. “It’s a sad statement about the lack of sensitivity that some of our health care providers have.”