NC Medicaid Administrative Barriers
for Moms and Babies
This report was drafted based on available information and data sourced throughout this document. The Southern Alliance for Public Health Leadership (SAPHL) convened a series of sessions over from May of 2026 through September of 2026 with subject matter experts and stakeholders across the state of North Carolina to collect their feedback and ideas on both where the system was breaking down and how it could work better.
1 Policy Landscape and Changes
Medicaid is a crucial and foundational safety net. Despite the vital role of this safety net, significant administrative and procedural barriers continue to hinder eligible families from accessing and maintaining coverage. Medicaid expansion in North Carolina had a dramatic, substantial and positive impact on North Carolina. Despite the expansion, the recent Medicaid "unwinding" period in mid-2023 underscored real systemic vulnerabilities, as 281,400 North Carolinians lost their health coverage - 86% for purely procedural reasons rather than a change in actual eligibility. While far better than what other states experienced, many people still lost overage. For moms and babies it also represents a breakdown in the essential continuous care for moms and babies during their most vulnerable stages. Furthermore, uncompensated care translates into severe health and economic costs for families, providers, and local health departments—entities that primarily serve women and children and rely on Medicaid as their primary client insurer.
Adding to these existing systemic vulnerabilities, County Departments of Social Services (DSS) across North Carolina now face substantial new operational, administrative, and financial demands introduced by federal HR 1 requirements. HR 1 significantly expands mandates around eligibility, verification, and reporting. These new federal requirements compound the existing workload pressures and staffing vacancies that are already overwhelming local offices. Compliance with HR 1's strict verification timelines will be impossible without significant state-supported technological modernization to address the ongoing manual processing limitations of the NC FAST system. To protect the stability of benefits for over two million North Carolinians and avoid severe federal fiscal sanctions, it is imperative that the state provide targeted partnership—including immediate investments in surge staffing, technology automation upgrades, clear policy guidance to programs and people impacted by these changes, and a temporary hold-harmless period to shield under-resourced counties during this complex transition.
Beyond general administrative burdens, specific procedural broken workflows prevent effective enrollment and retention. Families frequently navigate glitchy mobile interfaces and confusing communications—a barrier severely compounded by limited rural broadband access across many areas of the state.
While North Carolina has several policy bright spots and foundational strengths that serve as models for the region (including Medicaid expansion), there remain critical areas for improvement to fully protect vulnerable populations. This report, developed through a series of collaborative working sessions with regional leaders and advocates, aims to map these procedural fractures in exhaustive detail. By identifying the specific barriers—from the heavy reliance on Emergency Medicaid for births in certain counties to the nuances of presumptive eligibility—and analyzing them alongside the state's existing successes, we provide a balanced roadmap for Southern policymakers. The following sections will explore these challenges in depth, highlighting successful regional programs and offering actionable solutions to remove remaining red tape and ensure every eligible family in North Carolina remains covered.
1.1 New Laws Disrupting Medicaid Access for Families
North Carolina’s Medicaid system is undergoing a significant shift. While controversial bills aimed at changing hospital billing and managed care operations have stalled in the legislature, the state is actively implementing strict new work requirements and rolling back coverage for certain populations. Meanwhile, a major federal lawsuit is underway to protect the state's most medically frail patients from losing their care. Here is a look at the stalled proposals, the new laws, and the legal fights reshaping healthcare in North Carolina.
1.1a Enacted Medicaid Changes: Stricter Rules and Rollbacks
The state passed sweeping Medicaid legislation in April 2026 to address budget shortfalls. These changes align North Carolina’s Medicaid program with HR 1, are actively going into effect, and will profoundly impact beneficiaries via:
- Strict Work Requirements: Starting January 1, 2027, most adults (ages 19–64) in the Medicaid expansion group must meet new work or community engagement requirements to keep their coverage. North Carolina is implementing stricter rules than the federal baseline, requiring the state to verify a recipient's compliance for the three months preceding a new application.
- Immigrant Coverage Rollbacks: Effective October 1, 2026, North Carolina is ending its long-standing optional coverage that allowed lawfully residing pregnant women and children to receive Medicaid without a five-year waiting period. Coverage will now be strictly limited to the federal minimums.
- Increased Copays & Monitoring: The state is now mandated to set Medicaid copayments to the highest allowable federal limits for enrollees, and eligibility checks are moving from quarterly to monthly reviews.
1.1b The Medical Frailty Lawsuit
The incoming work requirements have triggered a massive legal battle over how the state's sickest patients are classified. In late June 2026, NC Attorney General Jeff Jackson and Governor Josh Stein joined 23 other states in suing the Centers for Medicare & Medicaid Services (CMS).
- The Core Issue: When the federal government mandated work requirements for Medicaid expansion, it included an exemption for those who are "medically frail" (such as patients with late-stage cancer, Parkinson's, or cystic fibrosis).
- The Rule Change: Over the summer of 2026, CMS abruptly tightened this guidance. Instead of simply relying on a serious diagnosis to grant an exemption, patients must now prove that their illness substantially limits their ability to meet the 80-hour-per-month work requirement.
- The Impact: State leaders argue this creates a mountain of unlawful red tape. Because of this change, tens of thousands of severely ill North Carolinians could needlessly lose their health coverage simply because their doctors are too overwhelmed to handle the new bureaucratic burden of proving their inability to work. The lawsuit is actively seeking to block this rule change to protect patients who are undergoing critical treatments.
2 Data and Demographics
2.1 The Coverage Landscape: Eligibility Versus Enrollment
A significant disparity exists between Medicaid or CHIP eligibility and active enrollment across North Carolina, demonstrating that income limits are not the sole driver of uninsurance. This is highlighted by the counties that have the highest uninsured rates among women at 200% of FPL.
| County ↕ | Uninsured Women at 200% FPL ↕ | CHIP ↕ | Uninsured Children (CHIP Eligible) ↕ | Medicaid ↕ |
|---|---|---|---|---|
| Chatham | 27.1% | 42.3% | 6% | 17.2% |
| Duplin | 25.9% | 49.8% | 7% | 24.6% |
| Lee | 25.3% | 47% | 6.6% | 22.8% |
| Mecklenburg | 24.6% | 33.3% | 6.4% | 16.3% |
| Greene | 22.8% | 51.3% | 8.4% | 25.1% |
The data across these five counties highlights the places experiencing the greatest gaps in coverage - some of which is likely due to administrative barriers and procedural friction. Most notably, nearly one in four women living at or below 201% of the Federal Poverty Level—the income threshold for Pregnant Women (PW) Medicaid—remains uninsured, with rates hovering tightly between 22.8% in Greene and 27.1% in Chatham. Furthermore, despite significant overall engagement with CHIP and Medicaid (particularly in rural Greene and Duplin counties, which show the highest metrics for both programs), a persistent gap of uninsured children explicitly eligible for CHIP remains, peaking at 8.4% in Greene. It’s also important and notable that unlike other states there is no clear profile of the composition of the eligible but uninsured - it spans urban and rural communities and isn’t geographically concentrated.
2.3 Access, Workforce Gaps, and the Fragility of Pediatric Care
Structural provider shortages further exacerbate the impact of administrative barriers. When a county lacks essential healthcare infrastructure, any lapse in insurance coverage can completely sever a family's access to maternal and pediatric care. The following five counties from across North Carolina highlight what these gaps in care look like and how it might relate to the uninsured but eligible population:
| County ↕ | March of Dimes Profile ↕ | % Births on Emergency Medicaid ↕ | Pediatricians ↕ | Uninsured Women (200% FPL) ↕ | Uninsured Children (CHIP) ↕ |
|---|---|---|---|---|---|
| Warren | Maternity Care Desert | 1.9% | 0 | 16.1% | 7.2% |
| Northampton | Maternity Care Desert | 1.4% | 1 | 13.1% | 4.9% |
| Yadkin | Maternity Care Desert | 7.1% | 0 | 21.9% | 6.1% |
| Anson | Maternity Care Desert | 3.1% | 0 | 16% | 5.3% |
| Jones | Maternity Care Desert | 1.9% | 0 | 15.4% | 6.1% |
The data above illustrates five of the counties with the most severely limited healthcare access in North Carolina, characterized by a dangerous intersection of clinical provider shortages and severe administrative coverage gaps. This physical infrastructure deficit is - in places - exacerbated by failures in program enrollment. There is not a corresponding increase in the use of Emergency Medicaid. Instead, we see the highest rates of emergency Medicaid rates in places like Chatham and Duplin.
2.4 Deficiencies and Errors in Medicaid
To understand what keeps eligible North Carolinians from accessing Medicaid, it is critical to evaluate how the state manages applications and renewals. To their credit, North Carolina DHHS proactively publishes an annual Medicaid Recipient Eligibility Determinations Audit. The most recent CY 2024 audit data provides clear evidence of the same systemic operational strain seen across the region.
Administrative failures made by agency staff in the application process take two familiar forms: "technical errors" (deficiencies) and "accuracy errors." Technical errors represent the improper application of procedural methodologies during the case review process, serving as an index of systemic friction. Accuracy errors, by contrast, denote severe instances where individuals are fundamentally misclassified—resulting in eligible applicants being incorrectly denied or rejected, or unqualified applicants being mistakenly accepted.
A high-level review of the state's audit highlights internal processing inaccuracies that routinely disrupt coverage. Statewide averages reveal a 95.0% approval accuracy rate, meaning 5.0% of approved cases contained fundamental eligibility errors. More concerning for health equity is the state's negative action data: the audit showed a 93.8% accuracy rate for denials and terminations, meaning 6.2% of individuals rejected or dropped from coverage were falsely or incorrectly locked out of Medicaid entirely. Alongside these hard errors, the state demonstrated an 11.8% technical error (deficiency) rate across the board. Just as in neighboring states, these statistics show that administrative errors are not isolated incidents but are symptomatic of a deeply flawed infrastructure where thousands of qualifying individuals are routinely separated from the healthcare safety net due to institutional mistakes.
The North Carolina data explicitly details the causes of these failures, showing that administrative breakdown is heavily concentrated around communication and documentation protocols. The vast majority of technical deficiencies (77%) and improper denials (81%) are driven by three specific administrative chokepoints:
- Requests for information
- Applicant/beneficiary notifications
- Income computation and verification
Closer inspection of these drivers reveals extreme vulnerabilities for low-income applicants. When over 80% of improper denials are rooted in basic procedural steps—like the state failing to properly send a notice or correctly compute provided income—it points to a collapse of standardized protocol during routine reviews. This high concentration of documentation-related failures suggests that even when an applicant submits their paperwork, the administrative process is heavily bogged down by procedural friction. Critical applicant information is routinely lost or mismanaged along the way, creating significant, sometimes insurmountable obstacles for families trying to establish or maintain their benefits.
Macro Context: Structural Failure vs. The "Training" Narrative
From an advocacy perspective, the North Carolina findings reinforce a frustrating systemic imbalance. State agencies and federal oversight mandates remain intensely hyper-focused on preventing consumer-level fraud and minimizing monetary loss. However, North Carolina's own data explicitly proves that the primary barriers to coverage are not intentional deception by applicants, but rather basic administrative missteps regarding how the state computes data and notifies beneficiaries.
Rather than acknowledging these deep infrastructural failures, state agencies frequently issue a standard rhetorical "cop-out," claiming that high technical error rates and improper denials are merely localized "staff training issues." This explanation completely ignores the reality that state agency staff are universally overworked, underpaid, and relying on flawed data tracking systems. Forcing additional training onto a collapsing, under-resourced workforce will never fix the underlying structural flaws embedded within North Carolina's eligibility infrastructure.
2.5 A Profile of Medicaid Recipients and Uninsured but Eligible
This data ultimately leaves us with three profiles that help us define who’s at risk and in what ways:
Profile 1: The Bureaucratic Bottlenecks
- Counties: Chatham, Duplin, Lee, Mecklenburg, Greene
- The Data: Approximately 23–27% of eligible pregnant women and 6–8% of eligible children are uninsured, despite these counties demonstrating strong overall Medicaid and CHIP enrollment. 6.2% of individuals are rejected or dropped from coverage are falsely or incorrectly locked out entirely due to institutional mistakes.
- The Story: When families fall off the roster, it is often not a failure to submit paperwork, but rather the administrative process breaking down around basic tasks like properly sending notices or computing income. Families in both urban (Mecklenburg) and rural (Duplin, Greene) communities know about the programs but are getting tripped up by renewal hurdles, paperwork requirements, and procedural red tape and are particularly vulnerable to the state's 11.8% technical error rate. The spikes in Emergency Medicaid usage in these specific areas indicate that families are often navigating the enrollment bureaucracy only when a clinical crisis forces them into the emergency room.
Profile 2: The Social Services Paradox
- Counties: Columbus, Robeson, Northampton, Montgomery
- The Data: These counties exhibit extremely high Maternal Vulnerability Index scores (88–91+) driven by severe socioeconomic and physical health stressors. Yet, they possess surprisingly lower rates of eligible-but-uninsured pregnant women (13–15%).
- The Story: Deep, systemic poverty inadvertently protects Medicaid enrollment. Because families in these counties are highly vulnerable, they are likely also relying on other, broader social safety net programs (SNAP, WIC, TANF, housing assistance). These continuous touchpoints with caseworkers and state systems create automatic prompts for Medicaid renewal. They hold the insurance card, but their underlying physical health and socioeconomic environments keep them clinically fragile.
Profile 3: The Healthcare Ghost Towns
- Counties: Warren, Yadkin, Anson, Jones
- The Data: Classified as Maternity Care Deserts with zero pediatricians. They maintain moderate-to-high uninsurance rates among the eligible (15–22%), but also show low usage of Emergency Medicaid (with Yadkin as an outlier).
- The Story: Medicaid doesn’t mean much because the physical infrastructure simply does not exist. The low Emergency Medicaid usage does not mean these populations are healthy; it suggests they are completely detached from local clinical care, unable to access even emergency services without traveling across county lines. Fixing administrative enrollment here only solves half the equation if there are no providers to accept the coverage.
3 Medicaid Communications and Awareness of Eligibility
The first hurdle in the Medicaid journey is often the basic recognition of eligibility—a process currently hindered by a lack of clear communication and systemic blind spots. Many families remain unaware of their options, and even those successfully enrolled often do not realize the full scope of services and supports available to them.
3.1 Discovery at the Point of Care: Presumptive Eligibility
For most pregnant women, awareness of Medicaid eligibility—specifically presumptive eligibility (PE)—does not occur until they physically arrive at a healthcare clinic. Some FQHCs rely heavily on their front desk and patient access staff to identify eligible patients, using targeted scripts and eligibility criteria slides to inform women of their options and initiate the application process before they leave. Once initiated, pending applications can immediately cover services like labs, with clinic staff further assisting by completing Department of Social Services (DSS) forms.
However, because there is no sustainable, proactive statewide outreach, the burden of discovery falls heavily on the patient at a highly vulnerable moment and the providers serving them. Furthermore, PE is mechanically limited: it only grants temporary coverage. If a mother does not successfully navigate the standard enrollment application before that brief window closes, she is left uninsured mid-pregnancy. This turns PE into a necessary but insufficient "band-aid" applied reactively, rather than a proactive, cohesive safety net.
3.2 Medicaid Enrollment: Systemic Communication and Transition Challenges
Even when women become aware of their initial eligibility, poor systemic communication creates confusion at later transition points. A primary barrier to awareness is the lack of public community outreach. As noted by partners, "no one is running around with a bullhorn" to educate the public about presumptive eligibility or the generous income requirements for pregnancy Medicaid. Consequently, women who do not immediately seek pregnancy confirmation at a well-resourced clinic frequently slip through the cracks. The method by which information is disseminated also limits coverage. In rural North Carolina communities—many of which are broadband deserts—families rely heavily on word-of-mouth. If a community's collective knowledge is outdated, or if the state's messaging fails to reach the target audience clearly, many remain unaware that they qualify.
3.3 The ePass Barrier and Infrastructure Gaps
Families are largely unaware of the state's electronic benefit enrollment portal (ePass), and there is virtually no outreach educating families on how to effectively use the system to verify identity, update cases, or submit documents. Local DSS offices often appear to be unfamiliar with its intricacies as well. Additionally, online portals like ePass and Healthcare.gov rely on Experian who requires credit checks for identity verification. This fundamentally disadvantages low-income applicants who lack established credit histories, effectively barring them from digital enrollment and forcing them into backlogged phone or in-person systems. For rural North Carolinians, these digital barriers are exacerbated by long physical distances to local county DSS offices.
3.4 Procedural Errors and Inaccessible Communications
Because of rigid administrative burdens, an estimated 80% of Medicaid terminations are driven by procedural errors—such as failing to receive or return mailed documents—rather than actual ineligibility. This is compounded by the fact that state notices are drafted with complex terminology well above the average reading level. By relying heavily on bureaucratic jargon like "MAGI" (Modified Adjusted Gross Income), "redetermination," or "spend-down," the state fails to communicate clearly with average applicants.
This lack of clarity is particularly dangerous for vulnerable populations and frequently lacks adequate translations for non-English speakers. Furthermore, the reliance on physical mail disproportionately harms transient, unhoused, or housing-insecure populations who lack stable mailing addresses.
3.5 Navigating Managed Care and Plan Selection
Even after successfully enrolling, beneficiaries face the immediate administrative hurdle of understanding North Carolina's Managed Care system. New enrollees must navigate selecting a health plan or risk being auto-assigned to one that their established providers do not accept. The complexities of understanding in-network versus out-of-network providers present a secondary barrier that prevents individuals from utilizing their coverage effectively.
3.6 The Postpartum Cliff and Administrative Churn
While North Carolina's recent Medicaid expansion and the implementation of a 12-month postpartum extension were assumed by many to eliminate gaps in coverage for new moms, the administrative churn of transitioning from pregnancy-specific Medicaid to standard Medicaid still leaves many women temporarily uncovered or lost in the system because of obtuse communication.
During this period, beneficiaries frequently operate under the incorrect assumption that their transition off the program means their children will also lose coverage. Furthermore, specific demographic groups, notably Latina and refugee communities, experience heightened fear regarding government interactions. Concerns surrounding the "public charge" rule deter eligible families—including those with U.S.-born children—from enrolling in or maintaining their required benefits.
3.7 Program Complexity and Workforce Bottlenecks
The overarching complexity of the Medicaid system acts as a substantial barrier to both enrollment and retention. This complexity is exacerbated by severe workforce challenges within the DSS, where staff are chronically overworked, underpaid, and subject to high turnover rates. Consequently, applicants often encounter inconsistent guidance and widespread confusion. While agency audits frequently identify application and enrollment errors, they tend to attribute these issues solely to a lack of staff training, failing to acknowledge the underlying structural and systemic flaws driving these inefficiencies.
4 Operational Challenges in NC Medicaid
4.1 Logistical Friction, ePass, and Credit Bureau Slowdowns
A disproportionate systemic focus on preventing consumer fraud as opposed to failure to enroll eligible residents has introduced immense bureaucratic hurdles into the enrollment process. These arduous verification requirements and convoluted workflows alienate legitimately eligible individuals, transforming the safety net into a deeply frustrating system.
A primary driver of this friction is the state's reliance on the electronic benefit enrollment portal (ePass). Families are largely unaware of ePass, and there is virtually no systematic outreach educating them on how to effectively use the system.
4.2 Emergency Medicaid and the Climate of Fear
The widespread reliance on Emergency Medicaid for labor and delivery serves as a glaring indicator of systemic and policy failure in North Carolina. As of October 2026, these numbers are projected to grow significantly, as many noncitizens who currently receive full Medicaid will lose comprehensive coverage and be restricted entirely to Emergency Medicaid.
- The CHIPRA 214 Mitigation: To mitigate this, North Carolina has elected the CHIPRA 214 option, ensuring lawfully residing children under 19 and pregnant women maintain full Medicaid or CHIP coverage. Executing this requires the state to identify and re-verify immigration statuses, update eligibility systems, and submit a State Plan Amendment by December 31, 2026. Beneficiaries are granted a 90-day Reasonable Opportunity Period to verify their status.
- A Fragile Safety Net: While intended only for acute medical needs, Emergency Medicaid has become the default financier for the majority of births in several counties. One Federally Qualified Health Center (FQHC) partner reported that 85% of its deliveries are covered through this program.
- The Climate of Fear: Many individuals bypass routine prenatal care entirely, waiting until they are in active labor to seek medical attention. This is driven heavily by a pervasive climate of fear, where visiting a doctor feels overwhelming due to anti-immigrant rhetoric and concerns over ICE presence. These anxieties, compounded by language and transportation barriers, discourage preventative care.
- Administrative Traps and Surprise Billing: The administrative structure of Emergency Medicaid leaves families financially vulnerable. The program operates under a narrow definition of "stabilization." Once a medical condition is no longer an immediate emergency—even if it remains serious—coverage ceases. This frequently results in families receiving exorbitant hospital bills for care provided post-stabilization. Furthermore, families can only apply within a rigid 45-day window of their due date; if delivery falls outside this timeframe, the application is denied.
4.3 Provider-Side Constraints Impacting Physical Access
Operational barriers extend beyond patient enrollment directly into the clinical infrastructure. Recent legislative changes designed as cost-saving measures—such as stricter guidelines on care settings and limitations on facility fees—are causing downstream effects that restrict patients from accessing eligible services.
Similar to trends seen across the rural South, the Medicaid framework places severe financial strain on healthcare providers. As reimbursement rates consistently fail to cover the actual cost of maternal care, rural labor and delivery units face increasing pressure to close. Crucially, healthcare providers and hospital social workers serve as essential, de facto navigators for vulnerable families trying to understand Medicaid. As more rural clinics and specialized providers close, communities lose not only clinical care but the critical administrative bandwidth needed to help patients untangle this opaque system.
4.4 Managed Care Organizations (MCOs) and Bureaucratic Labyrinths
The widespread implementation of Managed Care Organizations (MCOs) has introduced new layers of administrative complexity. Both patients and healthcare navigators struggle to resolve prior authorization disputes and frequently receive conflicting instructions from third-party contractors.
A primary example of this is the lack of transparency surrounding Value Added Benefits (VABs). Currently, there is little to no accountability ensuring MCOs actually deliver the specific benefits designed for infants and new parents. This confusion is compounded by the Medicaid Broker and MCO selection process, which is frequently described as opaque. Navigating this system to ensure a preferred rural or specialized provider is in-network requires an overwhelming amount of administrative effort from patients who are already navigating complex life circumstances.
4.5 The Postpartum Drop-Off and the "Individual vs. Family" Disconnect
Awareness and coverage severely break down one year after birth when mothers transition off postpartum Medicaid. Due to confusing, non-plain-language communications from the state and MCOs, many mothers falsely assume that when they lose their Medicaid coverage, their eligible children lose it as well. This administrative opacity leads directly to a steep drop-off in eligible child enrollment.
At the core of these barriers is a fundamental disconnect between the system’s design and the reality of the families it serves: North Carolina’s Medicaid infrastructure is built to "see" individuals rather than cohesive families. Because the system evaluates beneficiaries as single units, it fails to account for household needs, frequently resulting in family members being arbitrarily split across different MCO health plans or losing coverage unevenly.
Without dedicated, human-centered navigators to bridge these information gaps and guide families through initial applications and ongoing renewals, legitimately eligible mothers and infants will continue to fall through the cracks of a system that evaluates them in isolation.
5 Recommendations
Capitalize on Successes: The Economic & Workforce Case
It’s important to recognize the real progress in North Carolina. Advocates must anchor their advocacy in the state's recent triumphs, including the successful rollout of Medicaid Expansion, the leveraging of data cross-walks for Family Planning Medicaid, and the momentum around automatic enrollment strategies. To build on these successes we need to:
5.1 Operations
- Overhaul Data Systems and Surge Staffing: While many families remain unaffected by verification changes, bureaucratic bottlenecks slow the Department of Social Services (DSS) and increase error rates. Operational investments must include overhauling the flawed data tracking systems rather than simply forcing additional training onto an underpaid, overwhelmed workforce. Additional surge staffing to shield vulnerable county DSS offices from severe federal fiscal sanctions during complex transitions brought about by HR 1.
- Establish Postpartum "Warm Handoff": Treat the end of the 12-month postpartum extension as a managed transition rather than a cliff. NC Medicaid should fund dedicated navigators and CHW’s to actively transition mothers to the ACA Marketplace or Caregiver Medicaid rather than relying on automated termination notices.
5.2 Communications
- Beyond the Mailbox: Physical mail disproportionately fails transient families and rural communities. Rapidly expand SMS text messaging and multi-lingual outreach to supplement standard mail. Modernizing communication is required to address the state's failure in handling "requests for information" and "applicant/beneficiary notifications". Communication chokepoints, alongside income computation, are responsible for 77% of all technical deficiencies.
- Maximize NC ePASS & Community Tech: Drive families to utilize the NC ePASS portal, where they can directly apply, upload documents, and renew coverage without needing to visit local DSS offices. Bring this technology to the people by placing secure enrollment tablets or kiosks in schools, community centers, and local health departments.
- Humanize & Demystify the System: Ground public engagement in the real-life stories of North Carolina families, demonstrating how administrative barriers directly harm physical and mental health. Address confusing program jargon by clearly distinguishing between standard NC Medicaid, Emergency Medicaid, and Presumptive Eligibility.
5.3 Policy
- Maximize Automatic (Ex Parte) Renewals: Eliminate procedural paperwork by fully integrating cross-agency data. If a mother or child is financially eligible for SNAP or WIC, utilize that existing data to automatically renew their Medicaid coverage at the household level.
- Family-Centered PHP Alignment: Transition to an enrollment model that automatically aligns all household members within the same Managed Care Prepaid Health Plan (PHP) by default. Modernize data systems to ensure a parent's status change does not inadvertently trigger separate plan assignments or coverage drop-offs for their children.
- Expand Presumptive Eligibility (PE): Stop treating PE as a reactive, hospital-centric band-aid. Replicate regional best practices by establishing dedicated, walk-in PE clinics at local health departments. Grant PE determination authority to trusted Community-Based Organizations (CBOs), WIC clinics, and Federally Qualified Health Centers (FQHCs) to proactively capture uninsured pregnant women before a crisis.
- Direct Address Updates: Address notification failures at the root cause by legally authorizing MCO’s and contracted healthcare providers to directly update a patient’s contact information within the state’s eligibility system.
- Streamlining and simplifying income computation and verification: Because this is identified as one of the three specific administrative chokepoints driving over 80% of improper denials, a dedicated policy recommendation to automate or simplify this exact calculation is highly necessary.
6 Conclusion
North Carolina’s Medicaid program serves as an essential safety net for mothers and children, yet systemic administrative barriers, technological friction, and clinical provider shortages continue to prevent legitimately eligible families from maintaining continuous care. The heavy reliance on reactive measures like Emergency Medicaid, coupled with the bureaucratic complexities of Managed Care Organizations and the ePass portal, disproportionately harms rural, transient, and socioeconomically vulnerable communities.
However, the state possesses a strong foundation of recent successes, such as the rollout of Medicaid expansion and the use of data cross-walks, which can be strategically leveraged to modernize the current infrastructure. By implementing immediate operational investments like surge staffing for overburdened local Department of Social Services offices, maximizing automated household-level renewals through existing SNAP and WIC data, and proactively expanding Presumptive Eligibility to trusted community-based organizations, policymakers can effectively eliminate procedural red tape. Ultimately, shifting to a proactive, human-centered enrollment model that evaluates households as cohesive units will ensure that every eligible mother and baby in North Carolina receives comprehensive, uninterrupted healthcare without falling through administrative cracks.
2.2 Social Drivers of Maternal Vulnerability
By cross-referencing enrollment data with the Surgo Maternal Vulnerability Index (MVI), we can pinpoint which communities face the steepest barriers to maternal and child health and how that might compare to the eligible but unenrolled population. High MVI scores reflect systemic community-level stressors that compound the difficulty of navigating Medicaid enrollment. The data below gives us a look at the communities that have the highest maternal vulnerability in the state.
The primary factors contributing to maternal vulnerability in the counties with the highest risk are primarily driven by socio-economic factors and physical health. The bureaucratic requirements of maintaining health coverage become exponentially more challenging for expecting and new mothers. However, we also find that counties that have a greater risk for maternal vulnerability typically have lower uninsurance rates than wealthier communities with less risks for pregnant women.